Program Specialist - Referral Center - DHCH

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About Duke HomeCare & Hospice

Pursue your passion for caring with Duke HomeCare & Hospice, which offers hospice, home health, and infusion services across the region, as well as serves as the home forthe Duke Caregiver Support Program. Team members work closely with a patient's physician to provide comprehensive, individualized care in the comfort of their home or at our inpatient hospice facility in Durham, NC.

JOB SUMMARY:

As a liaison between the patient's payer source and DHCH programs (Home Health, Hospice, and Infusion), the Program Specialist-Authorizations accurately completes patient accounts according to departmental protocol, policies and procedures, and regulatory agency compliance. They obtain the initial authorization for services rendered by DHCH programs and are involved in obtaining additional authorization if necessary. The Program Specialist-Authorizations collaborates with internal customers to ensure timely and efficient patient admissions, and plays a critical role in helping DHCH programs receive payment for their services when claims are filed with the payer source. As an independent worker, this position is crucial in ensuring the success of DHCH programs

MAJOR JOB RESPONSIBILITIES: 

• Analyze insurance coverage and benefits for services to ensure timely reimbursement.

  • This involves assessing insurance policies, understanding coverage details, and making decisions to ensure proper reimbursement. Critical thinking is necessary to navigate complex insurance policies effectively.

• Obtain all Prior Authorization as appropriate based on insurance plan guidelines. Gather all necessary CPT or HCPC codes, calculate units and, lengths of therapies to submit to insurance plans for authorizations.  

  • obtaining Prior Authorization and handling the associated coding, units, and therapy lengths is a multifaceted task in the referral center that involves navigating insurance regulations, making judgments, and ensuring proper documentation. Critical thinking is crucial to ensure that patients receive the necessary treatments and therapies while complying with insurance guidelines and maximizing the chances of authorization approval.

• Resolve insurance claim rejections/denials and remedy expediently.

  • Identifying the reasons for claim rejections or denials, troubleshooting issues, and finding quick and effective solutions often requires critical thinking and problem-solving abilities.

• Evaluate diagnoses to ensure compliance with the Local Medicare Review Policy.

  • This task involves understanding policy guidelines and comparing them to patient diagnoses. Critical thinking is needed to assess compliance and take appropriate actions.

• Perform those duties necessary to ensure all accounts are processed accurately and efficiently.

• Determine the necessity of third-party sponsorship and process patients in accordance with policy and procedure.

  • Assessing whether a patient qualifies for third-

• Examine insurance policies and other third-party sponsorship materials for sources of payment.

  • This task involves interpreting policy documents to identify potential sources of payment, which requires analytical and critical thinking skills.

• Inform attending physician of patient financial hardship.

• Update the billing system to reflect the insurance status of the patient.

• Explain policies and procedures to pharmacy and/or home health team to resolve problems related to authorizations.  

• Gather necessary documentation to support proper handling of inquiries and complaints.

  • Collecting and organizing documentation to address inquiries and complaints effectively requires attention to detail and critical thinking.

• Assist with departmental coverage as requested.

• Document billing system according to policy and procedure.

• Enter and update referrals as required.

• Runs the authorization expiration report in the billing system and notifies the programs they need to determine if additional authorization will be required.

• Communicate with insurance carriers regarding clinical information requested and to resolve issues relating to coverage and payment.

  • Engaging in communication with insurance carriers often involves negotiating, problem-solving, and making decisions based on clinical information, all of which require critical thinking skills.

• Identify revenue cycle problems, research/analyze data to resolve issues, identify and select alternatives to address outstanding issues, and implement solutions for improvement.

  • Investigating the reasons behind claim denials and providing explanations necessitates analytical and critical thinking abilities.

• Performs special projects as assigned and other duties as requested. Some cross training is may be required.

  • Depending on the nature of the projects, they may involve unique challenges that require critical thinking to accomplish.

• Analyze medication order and calculate dosages to convert into billable insurance units required by insurance for review. This task requires regular collaboration with clinical staff.

  • Requires careful assessment, problem-solving, and attention to details to navigate the intricacies of insurance billing.

• Review medical criteria and guidelines for specific diagnosis codes to determine if patient meets insurance plan criteria to ensue payment of claim.

• Must navigate 4 service lines, Home Health, Home Hospice and Inpatient Hospice (Hock) and Home Infusion.

• Training and onboarding New Hires.

Education

Work requires knowledge of basic grammar normally required through a high school education and more complex mathematical principles, with some postsecondary education preferred. Additional training or working knowledge of related business.

Experience

Three years’ experience working in hospital service access, clinical service access, physician office or billing and collections. Or, an Associate's degree in a healthcare related field and one year of experience working with the public. Or, a Bachelor's degree and one year of experience working with the public. Pharmaceutical knowledge and experience preferred.

Degrees, Licensures, Certifications

N/A

Knowledge, Skills and Abilities 

This job requires strong verbal and written communication skills and the ability to analyze data, pay close attention to details, handle multiple tasks, and work independently. You should also be able to adapt quickly to changes, manage your time effectively, and meet deadlines. Additionally, you must possess strong analytical and organizational skills and develop and maintain professional relationships with patients, physicians, co-workers, and supervisors. It is essential to understand and follow all policies and procedures.

Duke is an 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 (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends onthe 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 essential job 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.