Program Specialist - Duke Homecare and Hospice

Duke University•Durham, NC

79d•Hybrid

About The Position

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 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. Hybrid after 90-day probation period - Must reside in North Carolina 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

Requirements

Work requires analytical, communication, and organizational skills generally acquired through the completion of a bachelor's degree program, along with one year of experience in program administration or event production.
OR-
Two years of postsecondary education with three years of experience in program administration or event production.
OR AN EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE
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.

Nice To Haves

Preferred three years of experience working in hospital service access, clinical service access, physician office, or billing and collections.
Preferred: CMA, LPN or Pharmacy Tech background

Responsibilities

Analyze insurance coverage and benefits for services to ensure timely reimbursement.
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.
Resolve insurance claim rejections/denials and remedy expediently.
Evaluate diagnoses to ensure compliance with the Local Medicare Review Policy.
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.
Examine insurance policies and other third-party sponsorship materials for sources of payment.
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.
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.
Identify revenue cycle problems, research/analyze data to resolve issues, identify and select alternatives to address outstanding issues, and implement solutions for improvement.
Performs special projects as assigned and other duties as requested. Some cross training may be required.
Analyze medication order and calculate dosages to convert into billable insurance units required by insurance for review.
Review medical criteria and guidelines for specific diagnosis codes to determine if patient meets insurance plan criteria to ensure payment of claim.
Must navigate 4 service lines, Home Health, Home Hospice and Inpatient Hospice (Hock) and Home Infusion.
Accurately transcribe referral orders from physicians and other providers into the appropriate systems (Epic and CareTend), ensuring all required information is captured and communicated to relevant departments in a timely manner.
Training and onboarding New Hires.