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. General Description of the Job Class Under the supervision of the Hospital Manager of Medical Staff Services/DUHS CVO, the Medical Staff Services Coordinator is responsible for coordination of aspects of DUHS Medical Staff Services office by providing essential verification and quality control functions to support DUHS's goals for credentialing and privileging health care providers while ensuring adherence to legal, regulatory, and delegated requirements. Assignments are planned and executed with considerable independence in compliance with established policies and procedures, bylaws, regulations and laws. Duties and Responsibilities of this Level - Organizing and directing of a comprehensive and specialized credentialing program to assure continued accreditation compliance by the Joint Commission, NCQA, and AAAHC, as well as any other regulatory organizations. - Interpretation, explanation and following all regulatory guidelines, including medical staff bylaws, fair hearing plan, rules and regulations and policies. - Maintaining accuracy in the Credentialing database to identify (and disseminate to others), medical staff members and their clinical privileges; prepares and maintains other related records and reports. Responsible for the accuracy and integrity of the credentialing and privileging database system and for data entry performed in the medical staff office. - Receives application/reappointment application from the CVO, oversees the completion of the credentialing process for medical, professional, and advanced practice professional staff and granting of clinical privileges/scopes practice for the DUHS Medical Staff. - Coordinating, monitoring and maintaining the credentialing and re- credentialing process. For reappointment applications, this includes gathering of additional data for incorporation into hospital-specific processes (i.e., QI elements, FPPE/OPPE process, etc.) and evaluation/analysis of confidential healthcare provider credentials for the initial appointment and reappointment processes prior to presentation for the Department Chair, Division Chief, and Credentials Committee review and action. - Works with medical staff leadership and hospital clinical staff for the approval and ongoing review of credentialed practitioners. - Monitoring and revising credentialing and privileging/scope of practice forms as needed. Ensures maintenance of medical staff, advanced practice professional staff, and professional staff files. - Scheduling and supporting (prepares agenda, attends and prepares minutes) the Credentials Committee. Provides support to the Credentials Committee chair as needed. May participate on other Hospital committees as requested. Uses discretion to escalate identified red flags to the Manager, Medical Staff Services/CVO Office. - Communicating medical staff information to appropriate departments; including approval notices to the provider, and other entities (if applicable). In addition, prepares reports to the respective boards to comply with their deadlines. - Demonstrates effective leadership skills and coordination of intra- department activities and inter-department integration. Assures necessary revisions are communicated with the Manager, Medical Staff Services/CVO Office for the ongoing development and implementation of policies and procedures that guide and support the provision of services. - May develop and facilitate the medical staff orientation, as well as other on-boarding activities, as requested by the Manager, Medical Staff Services/CVO Office. - Perform other related duties incidental to the work described herein. Minimum Qualifications Education - Work requires analytical, communications and organizational skills generally acquired through completion of a bachelor's degree program. - In lieu of bachelor's degree, four years relevant experience in Managed Care or Medical Staff Credentialing/Privileging (in addition to the experience requirement for the role) Experience One year of experience in a Medical Staff/Managed Care credentialing office Degrees, Licensure, and/or Certification Certification by NAMSS (CPMSM or CPCS) strongly preferred 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.

Job DetailsJob Location: SUN Behavioral Houston - Houston, TX 77054Position Type: PRNEducation Level: AssociatesTravel Percentage: NoneJob Shift: DaysJob Category: Health CarePosition Summary: Receives inquiry calls and assists the caller with scheduling a face-to-face assessment or provide triage to the appropriate community referral based on patient need. Assesses or ensures necessary assessment by a licensed RN for patients who present for assessment. Upon assessment of the patient, coordinates with the physician to ensure appropriate treatment is provided either at the hospital or another appropriate provider in the community. Ensures appropriate screening of medical and behavioral emergency conditions. Completes all administrative processes of the admission for treatment including, as appropriate, the initial authorization of care with the insurance company/third-party payor. Able to work through and accept referrals through various platforms, Kno2, Carelink, Open Beds, Xferral, Bed Board. Position Responsibilities: Clinical / Technical Skills (40% of performance review) Demonstrates excellent phone skills including inquiry calls, explanation of assessment processes, scheduling appointments and successful closure of a call while avoiding phone therapy. States the procedure for managing a crisis call and identifies when to activate EMS services. Identifies safety and risk of each call. Documents all inquiry calls, completely, to include all applicable information on prospect form in Wellsky. Makes appropriate referrals to community resources if not scheduling an assessment States the process and reasoning for all follow up calls either to confirm an assessment, inquire about no-show status, or rescheduling an assessment to include documentation reflecting same. Enters all inquiry calls into Wellsky with all data needed to further action or follow up Shows competency and understanding of the review of the medical screen; as appropriate, notifies the RN for additional review and action. States the working definition and procedure for managing medically and psychiatric emergencies according to EMTALA guidelines as well as hospital policies. Identifies and triages emergent patients and prioritizes care based on same. Completes the clinical screening and assessment tool (intake assessment) with concise, clear documentation. As applicable, identifies the need for additional screening for substance use, nutrition needs, functional needs, and abuse for children/adolescents, school and development screening. Demonstrates understanding of admission criteria for inpatient, partial hospitalization, intensive outpatient hospitalization and outpatient levels of care. Documents any special needs related to spiritual or cultural needs. Demonstrates a working knowledge of community mental health and substance use programs/referral to be offered for all patients not at imminent risk nor requiring services at a higher level of care as provided at the hospital. By demonstrating competency and thorough clinical understanding, ensures that each patient is seen by a physician or has had a consult by a physician to obtain treatment recommendations and disposition. Upon admission to a treatment program within the hospital, notifies the unit staff of the patients level of acuity, chief compliant and history of illness leading to admission, medical concerns and attending physician. Evidences understanding of all hospital required forms for admission and completion of these admission forms for each department as applicable. Knowledge of state local laws, ordinances and practices governing involuntary hospitalization and ensure compliance with same. Ensure correct information on EMTALA log to include all timelines and no blanks in documentation. Demonstrates understanding of utilization review process to include treatment criteria and precertification payor to obtain initial authorization of care and document same with pass to the Utilization Management team for concurrent reviews. Demonstrates an ability to be flexible, organized and function well in stressful situations. Treats patients and their families with respect and dignity, ensures confidentiality of patients records. Interacts professionally with patient/family and provides explanations and verbal reassurance as necessary. Ensures that documentation meets current standards and policies. Answers the telephone in a polite manner and communicates information to the appropriate staff/family member. Individuals with a Registered Nurse license: Enter orders into Wellsky for admission and other orders as needed. This includes the follow up documentation required for PRN medication and first dose monitoring Knowledgeable of medications, including psychotropic drugs, and their correct administration based on the age of the patient and their clinical condition as demonstrated by observation of education completed with the patient/family members Conducts nurse to nurse report. Perform other duties as required Safety (15% of performance review) Strives to create a safe, healing environment for patients and family members Follows all safety rules while on the job. Reports near misses, as well as errors and accidents promptly. Corrects minor safety hazards. Communicates with peers and management regarding any hazards identified in the workplace. Attends all required safety programs and understands responsibilities related to general, department, and job specific safety. Participates in quality projects, as assigned, and supports quality initiatives. Supports and maintains a culture of safety and quality. Teamwork (15% of performance review) Works well with others in a spirit of teamwork and cooperation. Responds willingly to colleagues and serves as an active part of the hospital team. Builds collaborative relationships with patients, families, staff, and physicians. The ability to retrieve, communicate, and present data and information both verbally and in writing as required Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word. Demonstrates adequate skills in all forms of communication. Adheres to the Standards of Behavior Integrity (15% of performance review) Strives to always do the right thing for the patient, coworkers, and the hospital Adheres to established standards, policies, procedures, protocols, and laws. Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence. Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources. Completes required trainings within defined time periods, as established by job description, policies, or hospital leadership Exemplifies professionalism through good attendance and positive attitude, at all times. Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws. Ensures proper documentation in all position activities, following federal and state guidelines. Compassion (15% of performance review) Demonstrates accountability for ensuring the highest quality patient care for patients. Willingness to be accepting of those in need, and to extend a helping hand Desire to go above and beyond for others Understanding and accepting of cultural diversity and differences QualificationsEducation Required: Meeting state requirements, a Bachelors or Masters degree in Nursing, RN license. Maintains education and development appropriate for position. Experience Required: One to three years of experience in a behavioral health setting. Preferred: Previous assessment and evaluation experience in a behavioral health setting.

Role Description Our Utilization Management RN (Registered Nurse) evaluates efficiency, appropriateness, and medical necessity for medical services and procedures for our Health Plan. This role uses clinical knowledge to provide judgment to review medical services with evidence-based criteria, authorize requested services as appropriate. Our Utilization Management RN will be responsible for referring questionable cases to medical directors to prevent unnecessary procedures, treatments, or prolonged hospital stays. Qualifications - Registered Nurse (RN) with current licensure in the state of Wisconsin. - 4 or more years of experience as a Registered Nurse in varied clinical settings (i.e., hospital, clinic, home care, skilled nursing facility, etc.). - 2 or more years of experience in Managed Care (i.e., prior authorization, utilization review). - Demonstrated experience managing and coordinating care effectively for case managed members. - Strong knowledge of current medical practices, medical coding, trends and patterns of care. - Familiarity with health plan operations, payer/provider relationships, and insurance benefits. - Strong diverse experience and expertise that includes: - The ability to work independently, manage a case load, and prioritization. - Excellent analytical, critical thinking, problem-solving skills and decision-making skills. - Excellent communication and interpersonal skills to work with members, providers, and teams. - Proficiency in Microsoft Office and healthcare software and systems. Requirements - Enjoy working with healthcare professionals to facilitate appropriate and quality services in a cost-effective manner to positively impact medical loss ratio. - Can work closely with Medical Directors to facilitate decision-making process for the Health Services department. - Have experience reviewing medical and behavioral health prior authorization requests for medical necessity and appropriateness of requested treatment according to medical policies and evidence-based criteria. - Have experience working closely with members of Health Services, and key contacts in Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment. - Can document case summaries and refer cases to Medical Director that do not meet internal or external guidelines, policies, or medical criteria. - Like to be accountable to monitor and maintain inventory in the Utilization Management queue to meet productivity standards. - Enjoy evaluating, analyzing, and reporting trends in utilization changes in all healthcare delivery areas. - Can make recommendations and implement changes consistent with Health Services objectives of quality care and reasonable cost. - Would enjoy identifying opportunities and provide recommendations to improve department processes. - Have identified legal or liability issues and refer potential ethical or risk management issues to the appropriate department for resolution. - Have participated in training new nursing staff on department workflows, policies, and procedures. - Can work cross functionally to support other departmental efforts to ensure overall efficiency, quality, productivity, and compliance with all departmental, regulatory and URAC standards. Preferred Qualifications - Bachelor’s degree in nursing (BSN). - Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement plans. - Knowledge of Utilization Review Accreditation Commission (URAC). - Certified Managed Care Nurse (CMCN). - Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software. Remote Work Requirements - High speed cable or fiber internet. - Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net ). Benefits - Remote and hybrid work options available. - Performance bonus and/or merit increase opportunities. - 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately). - Competitive paid time off. - Health insurance, dental insurance, and telehealth services start DAY 1. - Professional and Leadership Development Programs. - Review additional benefits: https://www.wpshealthsolutions.com/careers/ .

Overview The ROI Specialist is responsible for providing support at a specified client site for the Release of Information (ROI) requests for patient medical record requests* Responsibilities - Determines records to be released by reviewing requestor information in accordance with HIPAA guidelines and obtaining pertinent patient data from various sources, including electronic, off-site, or physical records that match patient request. - Answer phone calls concerning various ROI issues. - If necessary, responds to walk-in customers requesting medical records and logs information provided by customer into ROI On-Line database. - If necessary, responds and processes requests from physician offices on a priority basis and faxes information to the physician office. - Logs medical record requests into ROI On-Line database. - Scans medical records into ROI On-Line database. - Complies with site facility policies and regulations. - At specified sites, responsible for handling and recording cash payments for requests. - Other duties as assigned. Qualifications - Demonstrates proficiency using computer applications. One or more years experience entering data into computer systems. Experience using the internet is required. - Demonstrates the ability to work independently and meet production goals established by MRO. - Strong verbal communication skills; demonstrated success responding to customer inquiries. - Demonstrates success working in an environment that requires attention to detail. - Proven track record of dependability. - High School Diploma/GED required. - Prior work experience in Release of Information in a physician’s office or HIM Department is a plus.Knowledge of medical terminology is a plus. - Knowledge of HIPAA regulations is preferred. *This job description reflects management’s assignment of essential functions. It does not prescribe or reflect the tasks that may be assigned. MRO’s employees work at client facilities throughout the United States. We are proud of the culture we create for our employees and offer an outstanding work environment. We strive to match the right applicant to the right position. To learn more about us, visit www.mrocorp.com. MRO is an Equal Opportunity Employer.