Compliance Specialist

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Patient Revenue Management Organization

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Compliance Specialist – Medical Necessity and Authorization Denials

JOB DESCRIPTION:

Compliance Specialist position reporting to Manager of Medical Necessity and Authorization Denials that supports quality audit of Authorization and Medical Necessity internal and vendor staff to ensure quality, appropriateness of appeals, the effectiveness of denial review, etc. The position will also be responsible for assisting with onboarding new staff, preliminary audits, special projects as deemed appropriate, etc.

· Quality Audit and QC – (80%) – Perform a monthly audit on internal authorization and medical necessity denials staff to determine compliance/quality of review and appropriate working of authorization and medical necessity denials. Perform monthly QC on authorization and medical necessity vendor completed audits to confirm accuracy and appropriateness of vendor audits. Perform preliminary audits for new internal and vendor staff.

• Communicate quality audit expectations with PRMO Internal Controls staff
• Perform monthly audits and QC on all staff using departmental policies and procedures to determine accurateness and education needs
• Summarize education needs according to audit results and communicate to leadership
• Assist leadership with staff education as needed

· Special Projects – (20%) – Assist management with special projects requiring clinical and or coding review related to Medical Necessity authorization denials

• Assist and attend meetings as delegated by management related to Medical Necessity or Authorization denials requiring clinical, payer policy, or coding knowledge when appropriate
• Support management with analysis and detailed review of medical necessity and/or Authorization denials and claims projects requiring coding and/or clinical knowledge.
• Act as staff resource for Coding and account questions
• CRM backup for medical audit customer service inquiries

Required Qualifications at this Level

Education:

Work requires organization, analytical, and communication skills generally acquired through the completion of a bachelor’s degree.

Experience

Four years of administrative experience to acquire competence in applying compliance, coding, and auditing principles as they relate to insurance billing, collections, consulting, and other revenue cycle-related functions.

Clinical and/or coding certification preferred.

Degrees, Licensure, and/or Certification:

Coding Certification Preferred (CPC, CCS, CPMA or RHIT, etc.)

Clinica l experience preferred

Knowledge, Skills, and Abilities:

Coding and/or clinical experience

Outpatient and/or Inpatient coding experience

Effective written and verbal communication skills

Ability to communicate with customers/staff with diverse educational backgrounds

Ability to provide feedback and education in a group setting or over WebEx, Zoom, Teams, etc.

Analysis of data and processes for opportunities for improvement

Attention to detail and accuracy

Organizational skills and ownership of folders and drives

Minimum Qualifications

Education

Work requires organization, analytical, and communication skills programs. generally acquired through the completion of a bachelor’s degree

Experience

Four years of administrative experience to acquire competence in applying compliance, coding, and auditing principles as they relate to insurance billing, collections, consulting, and other revenue cycle-related functions. For technical coding, two of the four years of experience with DRG's and APR-DRG's is required. Experience in formal teaching of coding is preferred. RHIA or RHIT or CCS is required. For professional coding, specialty coding experience in surgical or E/M coding is preferred. CPC or CCS or RHIT or RHIA or CPMA is required.

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 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 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.