PRMO:, established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke PrimaryCare. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Duke's reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.
General Description of the Job Class
Contribute to the achievement of the DUHS mission through the development and leadership of performance improvement activities in the operational and/or clinical arenas. Assure continual compliance with regulations and accreditation standards through monitoring activities and the design and implementation of strategies to enhance compliance. Responsible for billing and claims functions and overall management of the provider enrollment processes associated with enrolling applicable Health Systems and Physicians for all clients. Oversees and coordinates insurance collections and accounts receivable for the purpose of maximizing reimbursement, achieving A/R aging targets, minimizing avoidable/controllable write-offs, and accomplishing results as cost-effectively as possible.
Duties and Responsibilities of this Level:
Drive independent revenue cycle operational decisions to resolve complex issues impacting collections, patients and providers.
Prepare weekly report summarizing inventory statistics, staff productivity and collections performance, and accounts receivable aging trends.
Identify deficiencies in staff performance and backlogs in inventory statistics in a timely manner, and take action to address outstanding issues.
Work with Denials Analyst to monitor denial rate trends, and identify &implement opportunities to reduce post-billing denial rates.
Review and approve write-off requests per policy. Provide feedback to supervisor and staff if write-of requests are not in compliance with policy requirements.
Review avoidable write-off trends, and identify & implement opportunities to reduce avoidable write-offs.
Work with other PRMO management and DUHS leadership to improve collections, reduce accounts receivable, reduce denial rates, and reduce avoidable write-offs through issue identification, research, communication, and process improvement.
Pull reports to review aged outstanding insurance accounts receivable, and take necessary action to address backlogs or to identify unworked accounts.
Define criteria and set up for insurance work files/worklists to ensure timely and comprehensive collection of all accounts receivable.
Assign staff to all insurance work files/worklists to ensure appropriate and equitable resource allocation and prioritization to outstanding workload.
Review daily/weekly/monthly system reports summarizing inventory and staff performance to identify outstanding issues, including:
Activity Code Utilization reports
Provider Enrollment status reports
Work group issue log maintenance
Prepare operational status updates on High Balance accounts for weekly management meeting and review
Prepare a monthly summary of accounts receivable by entity/division/pay or for senior manager and director review, with explanation for changes in performance and specific plans to address deficiencies
Research operational and system issues identified by collectors, and develop/implement solutions for performance improvement
Oversee supervisor's efforts in posting, recruiting, and hiring new employees.
Oversee supervisor's efforts to provide job-specific training to new and existing employees.
Oversee supervisor's mid-year and year-end performance evaluations of employees.
Post, recruit, and hire direct reports (supervisors).
Provide job-specific training to new and existing direct reports.
Conduct mid-year and year-end performance evaluations and provide feedback to direct reports.
Review results of monthly employee quality reviews, and take action on underperforming staff results.
Ensure that all provider enrollment processes are completed in an accurate, timely manner and that credentials are up to date.
Oversee the claims billing and provider enrollment workgroup functions to ensure appropriate logic in place for revenue success.
Oversee all revalidations and reverifications related to enrollment to ensure timely completion.
Support the supervisor in oversight of completing enrollment packets for providers and groups in an accurate and timely manner.
Assist with the development of job specific training programs for all staff within team.
Identify and implement programs to develop direct reports and associated staff for career development.
Hold monthly team meetings to review team performance, share new policy and procedures, and keep employees informed about PRMO updates.
Identify and implement opportunities for improvement of staff morale.
Ensure compliance with all PRMO and DUHS personnel policies.
Policy & Procedure and Internal Controls
Develop and maintain documentation summarizing workflow processes and operating policy& procedure for all functions handled by team.
Document and review changes to all operational processes with department senior manager and director prior to implementation.
Develop internal controls for all operational processes, and ensure the timely completion of internal control processes by staff, supervisor, and manager on assigned periodic basis.
Prepare and submit for approval an annual budget for the team.
Review actual vs. budgeted variances on a monthly basis, and provide summary of explanation to senior manager and director.
Identify negative budget variances, and provide explanation and game plan for addressing deficiencies.
Identify opportunities to reduce or minimize personnel and non-personnel costs
Respond to inquiries from PRMO and DUHS leadership, peers, and staff in a timely, accurate, and comprehensive manner (i.e.: 24-48 hours, depending on circumstances).
Adhere to all PRMO and DUHS revenue cycle policies and regulations.
Respect and maintain confidentiality regarding patient/ guarantor financial data and patient medical data consistent with HIPAA standards.
Validate and reassess productivity standards through observations, documenting and sharing for management review and recommend resolution/feedback.
Provide coverage for Director in her /his absence.
Provide coverage for Supervisor in her/his absence.
Responsibility for all supervisor responsibilities on smaller teams that do not have a supervisor.
Establish and maintain a network of key co ntacts from provider representatives to senior level management with various carriers and departments to expedite and encourage effective enrollment and billing execution.
Assure that the department tracks and follows through on provider documents that areset to expire and notify customers timely.
Other duties as assigned.
Develop and maintain a working and effective knowledge of all functions performed by team.
Develop and maintain a working knowledge of relevant pay or billing requirements and reimbursement regulations.
Interpret and analyze data associated with Provider Enrollment payer regulations, keeping up with all mandates.
Develop and maintain a working knowledge of all core systems (Epic) and ancillary systems (Availity, SAP, ECHO, Hyland, Cognos/ReportNet) utilized by team.
Develop and maintain complete understanding of all operational policies and procedures relevant to team.
Develop and maintain working and proficient knowledge of personal computer software required for fulfilling management responsibilities, including: Lotus Notes, Excel spreadsheets, Word processing, Access database, Visio flowchart, Powerpoint presentation, TeamTrack Change Controls, Pillar budget, SAP, I-forms, and API PTO.
Work requires 5 years of experience in business or other applicable experience.
Six years of experience in the healthcare industry is required.
Knowledge of accounts receivable and revenue cycle management required.
Management experience is preferred.
Knowledge of provider enrollment processes and requirements for commercial insurance companies, CMS Federal and State Guidelines related to enrollment and reenrollment policies is preferred.
A master's degree in a related field, such as business or health administration, may be substituted for experience on a 1:1 basis.
Familiar with group and provider documents, ie: medical license, medical school practices, board certifications, etc. preferred.
Knowledge of claims billing payer regulations preferred.
Knowledge of Epic preferred.
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.