Director, Preservice Verification, PRMO

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

 

About Duke Health's Patient Revenue Management Organization

 

Pursue your passion for caring with the Patient Revenue Management Organization, which is Duke Health's fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions.

General Description of the Job Class

The Director, Preservice Verification, PRMO provides management oversight across all Duke Health entities for the verification prior to date of service of insurance coverage related to eligibility, authorization, and medical necessity across all payors – and the processing of downstream payor denials and appeals related to authorization and medical necessity.   The Director ensures that all operations align with PRMO and Duke Health goals and initiatives with an emphasis on our Balanced Scorecard objectives:  Operational Performance, Customer Service, Employee Work Culture, and Financial Controls.  The Director leads the department in a manner that is patient-centered and respectful of all employees and stakeholders, including modeling of the PRMO’s Mission, Vision, and Values.

 

Duties and Responsibilities of this Level

A. Plan, direct and coordinate all activities of Preservice Verification - 70% of time spent

• Identify, communicate and align overall strategy for department improvement across the system. Develop departmental strategies to meet overall PRMO goals and performance metrics.
• Work with entity leadership, departmental managers, revenue managers, and physicians to identify opportunities for improving revenue cycle performance and metrics associated with previsit clearance of eligibility/authorization/medical necessity payor requirements, and downstream reduction of associated denials and write-offs in a timely, comprehensive, and compliant manner.
• Formulate and administer enterprise level policies and procedures; ensuring compliance with state and federal regulations, and all payor requirements.
• Maintain working knowledge of payor requirements related to eligibility, authorization, and medical necessity.
• Review monthly trending analysis of denials and write-offs related to registration/eligibility, authorization, and medical necessity to effectively communicate and message performance to leadership constituents across Duke Health, and provide feedback/guidance to management team about areas of focus for performance improvement.
• Develop and implement strategies to reduce denials and write-offs through provider feedback/education, effective working of system edits related to payor requirements, and enhancements to appeal strategies with payors.
• Manage internal control performance for Preservice Verification department and associated functions & workflows.
• Ensure management compliance with documented and established workflow guidelines and procedures.
• Serve as expert on institutional questions related to industry and payor regulations related to registration/eligibility, authorization, and medical necessity.  Engage with other departments as needed to ensure compliance.
• Actively direct outsourcing and vendor relationships.  Monitor cost and evaluate utilization of any vendor relationships assigned to department cost center.
• Take leadership role in technology implementations affecting department. Assist in identification of new technologies that will improve financial service operations.
• Serve as an internal consultant on eligibility, authorization, and medical necessity issues with Duke Health and PRMO leadership.

 

B.  Serve as part of the overall leadership team of the Patient Revenue Management Organization as it relates to providing input on the overall strategy and vision for the Revenue Cycle – 20 % of time spent

 

• Develop and achieve PRMO and Department Balanced Scorecard goals. 

 

•    Develop and promote PRMO strategic Mission, Vision, and Values while emphasizing   

   teamwork and results.

 

•   Effectively define relevant customers and stakeholders for department management and staff. Utilize trending tools and communication plan for departmental staff related to customer service measures.  Ensure measurable customer service standards are part of every employee's expected job results.

 

•   Strive for excellence in Diverse and Inclusive behaviors.  Invest in Diversity growth and