Reimbursement Specialist - Outpatient Medication Authorization - Remote

Duke University - Durham, NC

Full-time - Mid Level

Remote - Durham, NC

Educational Services

About the position

The Reimbursement Specialist for Outpatient Medication Authorization at Duke Health plays a crucial role in the Patient Revenue Management Organization, focusing on the verification of patient insurance eligibility, prior authorization, and medical necessity for services provided across the health system. This remote position involves quality auditing, outsourcing support, and collaboration with various stakeholders to ensure compliance and enhance workflow efficiency.

Responsibilities

• Perform regular quality audit/control reviews on internal and external staff according to department policies and procedures.
• Review authorization denials and analyze to determine/assign root-cause.
• Maintain electronic documentation files to record all quality scores, ensuring compliance guidelines are met.
• Trend and report overall quality scores and feedback on the team's performance.
• Support management/supervisors in overseeing outsourced vendor books of business to ensure inventory, productivity, and quality guidelines are achieved and maintained.
• Aid in the oversight of work queue inventories, productivity/quality reporting, and confirmation of monthly invoicing.
• Respond to external staff questions timely regarding accounts or processes as defined by department policies and procedures.
• Communicate process changes and training to vendors as needed.
• Research accounts and respond with accurate findings/instructions in a timely manner.
• Interact with and provide verbal/written responses to all stakeholders (patients, providers, payors, and departmental personnel).
• Participate in the development of operational goals and objectives for the team; recommend, implement, and administer processes and procedures to enhance workflow.
• Assist management in training documentation related to findings from quality reviews/audits.
• Attend and/or facilitate regular training sessions to maintain knowledge of practice/protocol related to timely filing adjustments as needed.
• Partner with supporting clinics to educate on authorization processes and resolve problems relating to patient appointments/admissions as needed.
• Conduct observations of staff/process to look for operational improvements and share recommendations with management.

Requirements

• High school diploma or equivalent is required, preferably supplemented by post-secondary courses in Accounting, Finance, Economics, Business Administration or a related field.
• Four years of related experience in healthcare is required, or a Bachelor's degree in a related field can substitute for the experience requirement.