Director, Preservice Verification, PRMO

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Patient Revenue Management Organization

Pursue your passion for caring with the Patient Revenue Management Organization, which is the 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 for Duke Health.

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

• 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

• 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 development of management and staff by encouraging and modeling behavioralexpectations on a daily basis while continuing to keep Diversity and Inclusion at the forefront.

• Create and foster a department culture that provides a satisfying and enriching environment in which staff can be developed and retained. Support the PRMO Work Culture Initiatives to improve reward and recognition programs.

C. Primary responsibility for administrative functions for Preservice Verification department including: budget development and management, departmental work culture development/maintenance; mentoring, coaching of direct reports

• Develop, review, and approve departmental budgets. Ensure appropriate use of all resources.
• Communicate budget results to management staff and assist in budget management.
• Support and approve system process improvements to decrease costs and improve service for applicable stakeholders
• Ensure provision of education and training to management and staff employees in areas relevant to PreVisit Verification policies and procedures
• Monitor local, national, and international trends in payor coverage related to eligibility, authorization, and medical necessity

Manage human capital and resources-onboarding, succession planning, recruitment strategies and employee engagement

Required Qualifications at this Level

Education:Bachelor's degree required. Master's degree preferred.

Experience:8 years progressive experience in clinical/administrative/consulting responsibilities in or with a provider or payor healthcare environment is required, of which 5 of those years should be in management of people or projects. Extensive experience working with clinical providers required.

Knowledge, Skills, and Abilities:

Technical: Solid understanding of payor coverage requirements related to eligibility, authorization, and medical necessity.Knowledge of procedure/diagnosis coding, and case management/utilization review functions.General understanding of all revenue cycle functions and interrelationships.

Non-technical: Strong leadership presence and skills.Proven capabilities in building and leading teams.Ability to work with others in a cooperative, collaborative manner.Strong written and oral communication skills.

Systems: Epic experience preferred; MS Office Applications (Word, Excel, Visio, Access).