Duke University Health System (DUHS) Job Descriptions

SERVICE ACCESS ADV PRACTITIONER

Job Title: SERVICE ACCESS ADV PRACTITIONER
Job Code: 5597
FLSA: E
Job Level: H2
Revised Date: 09/01/2019
Supervisory Responsibility:

~ Printer-Friendly Version ~

General Description of the Job Class

Conducts medical chart audits and Peer-to-Peer conversations with payor Medical Directors to assess and prove medical necessity for appropriate insurance pre-authorization.

Duties and Responsibilities of this Level

Authorization Support/Liaison:

Non-clinical support role as an APRN that will synthesize the complexity of the patient population and support the efforts to obtain authorization by performing needed provider Peer-to-Peer conversations to facilitate prior approval of services.

Validate accurate commercial payer authorizations and mitigate occurrence when requirements of admission are not met/authorized resulting in MD Overrides (MDO).

Utilizing acquired advanced clinical knowledge and skills preparing him/her to provide indirect care and knowledge supporting the efforts of the PRMO in obtaining authorizations that are medically necessary for patients.

Reviews records for authorization criteria, medical necessity, physician orders, and level of care to assist with completing requirements for authorization. Document for future educational opportunities.

Liaison to payer for all hospital, PDC and PRMO staff including physicians, clinical nurses, patient resource managers, and clinic staff.

Act as an Advanced Practice resource for staff regarding authorizations that require detailed evaluation of clinical documentation. Assist with clinical questions and facilitate peer-to-peer conversations with insurance carriers and/or physician and staff.

General:

Contributes to a positive working environment and performs other duties as assigned/directed to enhance overall efforts for Duke Medicine to ensure authorization of various diagnostic procedures, oncology infusions, or surgeries.

Technical Expertise:

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 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 management responsibilities, including: EPIC, Excel, Microsoft Word,

Perform other related duties incidental to the work described herein.

Required Qualifications at this Level

Education

Work requires completion of an accredited Nurse Practitioner program, with a Master's degree in Nursing.

or

Completion of an accredited Physician Assistant program. A Bachelor's degree required; Master's degree strongly preferred.

Experience

5 years' experience in advanced clinical practice.

Degrees, Licensure, and/or Certification

Must possess current licensure as a Nurse Practitioner or Physician Assistant in the State of North Carolina.

Knowledge, Skills, and Abilities

Ability to establish good working relationships with the Medical Directors of the PRMO, Utilization Management, associate departments, internal staff, and payer Medical Directors.

Excellent communication skills; written and verbal.

Excellent customer service skills, including phone etiquette. Consider Moving to Knowledge, Skills, and Abilities

1. Who has passed a National Certification examination that measures Advanced Practice Registered Nurse or Physician Assistant, role and population-focused competencies and who maintains continued competence as evidenced by recertification in the role and population through the national certification program;

2. Who has acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all Advanced Practice Registered Nurses and/or Physician Assistants is that a significant component of the education and practice focuses on direct care of individuals;

3. Whose practice builds on the competencies of Registered Nurses (RN) by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy;

4. Who is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions;

5. Who has clinical experience of sufficient depth and breadth to reflect the advanced practice role.

Distinguishing Characteristics of this Level

---

The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

---

Duke University is an Affirmative Action/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, sexual orientation, or veteran 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.