Revenue Integrity Analyst, Remote, M-F

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.

Pursue your passion for caring with the Patient Revenue Management Organization, which is the fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions for Duke Health.

General Description of the Job Class:

• Reviews accounts and complete medical records to assess accurate patient class, utilization review outcomes, medical necessity/level of care, etc. in support of overturning insurance denials.
• Initiates actions to obtain appropriate insurance adjudication decisions and/or resolve customer inquiries, including but not limited to completing appeals, working with other internal departments, contacting the payer, etc.
• Exercises independent decisions using analytical and problem‑solving skills.

• Reviews records for medical necessity, accurate patient class, physician orders, authorizations, level of care, etc. to determine course of action to overturn insurance carrier denial or resolve customer service inquiries.
• Review chart and medical policy on denied accounts, determine appeal potential.
• Utilize Interqual and/or Milliman criteria to support accurate denial adjudication.
• Collaborate with Pre‑Registration, Coding, Billing, UM, etc. to affect positive denial resolution.
• Prepare appeal letters and documentation packets to facilitate overturned denial decisions.
• Provide any needed documentation to justify appeals, including but not limited to letters of medical necessity, case briefs outlining disposition reversal, NCCN/FDA/CMS guidelines, peer‑reviewed journal references, etc.
• Submit write‑off requests per policy.
• Provide formal and informal education and feedback with other healthcare teams, revenue cycle, providers, etc. to improve collections, reduce accounts receivable, reduce denial rates, and reduce avoidable write‑offs through issue identification, research, communication, and process improvement.
• Acts as a consultant/liaison to other PRMO teams when additional information or documentation is needed to resolve denied accounts.
• Assist with retroactive authorizations.

• Validate accurate payer authorizations, review CPT, ICD‑10, PCS, and HCPCS coding on denied claim, review billing accuracy.
• Review and complete Customer Service requests to ensure services performed were charged/captured accurately.
• Clinical and health care financial resources to PRMO and broader health system membership.
• Medical Policy liaison for hospital, PDC and PRMO staff including physicians, clinical nurses, patient resource managers, clinic staff, etc.
• Contributes to a positive working environment and performs other duties as assigned/directed to enhance overall efforts for Duke Medicine.

• Develop and maintain a working and effective knowledge of all functions performed by team.
• Develop and maintain a working knowledge of relevant payor billing requirements, medical policies, and reimbursement regulations.
• Develop and maintain a working knowledge of all Maestro Care and ancillary systems utilized by teams.
• 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 responsibilities, including Excel, Word, PowerPoint, Payroll software, Payer Portals, reference sites such as Up To Date , NCCN, etc.

Education:

Bachelor’s degree required. Clinical background and/or coding experience are strongly preferred.

Experience:

Work requires a minimum of 5+ years of healthcare experience, including appeals experience, payer experience, clinical, and/or coding experience, etc.

Knowledge,…