Primary City/State:

Arizona, Arizona

Department Name:

PHSO Med Claims Review

Work Shift:

Day

Job Category:

Clinical Care

The future is full of possibilities. At Banner Plans & Networks, we’re changing the industry to reduce healthcare costs while keeping members in optimal health. If you’re ready to change lives, we want to hear from you.

Banner Plans & Networks (BPN) is an integrated network for Medicare and private health plans. Known nationally as an innovative leader, BPN insurance plans and physicians work collaboratively to keep members in optimal health while reducing costs. Supporting our members and vast network of providers is a team of professionals known for innovation, collaboration, and teamwork. If you would like to contribute to this leading-edge work, we invite you to bring your experience and skills to BPN.

As a Registered Nurse Auditor, you will serve as a vital part of the Banner Plans and Networks Team. In a collaborative environment, you will work alongside other RN Auditors, Providers, Leaders, and Provider Staff. Your role will involve auditing charts for medical necessity and compliance, as well as serving as an educational resource for the team.

This position is fully remote, with a four-day workweek, 10 hours each day, from either Monday to Thursday or Tuesday to Friday. Required work on holidays will be minimal and based on critical business needs. Please note this role does require Arizona Residency for compliance. If this role appeals to you, apply today.

Banner Health Network (BHN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BHN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.

POSITION SUMMARY
This position audits the organization's RN Reviews/Case Managers for adherence to established policies and guidelines surrounding case reviews for medical necessity. Uses critical thinking to audit clinical documentation confirming appropriate application of evidence based clinical criteria and proprietary tools and adherence to established productivity requirements. The position requires a sound knowledge of applicable regulations, including Medicare and Medicaid and has an understanding of our large commercial plans. Conducts telephonic audits, ensuring adherence to Banner’s Core Behaviors.

CORE FUNCTIONS
1. Performs audits for inpatient and/or outpatient cases, procedural processes and other potential compliance risk areas. Audits medical records to monitor compliance ensuring adherence to established processes and workflows. Identifies areas of potential risk through audit processes, as well as assists with presentation of audit findings and design and monitoring of necessary corrective action.

2. Researches regulatory and medical necessity requirements and develops audit tools and report forms at the direction of the Care Management leadership.

3. Identifies training opportunities based on audits, designs and presents such education to prevent repeated compliance risks at the direction of the compliance leadership team. Provides compliance/documentation education sessions to Medical Directors of Care Coordination (MDCC) RN Reviewers, Case Managers and other staff.

4. Acts as a knowledge resource to the registration staff as to requirements for compliance with specific regulatory and accreditation requirements for federal, state and third party agencies. Pursues and participates in education to remain current with changes in the healthcare and insurance industries. As assigned, provides training for RN Reviewer/Case Management staff and other staff.

5. Assists the organization's compliance officers, as directed, to research and investigate complaints, concerns or questions relative to compliance issues. Investigates and follows up on reported issues as directed.

6. Maintains awareness of laws and regulations and conducts research as needed to identify applicable laws, regulations and practices to maintain compliance. Reviews related policies and procedures and literature. Communicates applicable medical necessity compliance issues to Care Management leadership and assists in the distribution of training of such changes.

7. Assumes additional responsibilities to assist and support the organization's compliance program often dealing with complex and unique situations and problems.

8. Performs job functions on a system-wide basis. Internal and external customers include, but are not limited to, executives and managers, compliance committees, physicians and clinical staff.

MINIMUM QUALIFICATIONS

Requires knowledge typically gained with completion of a bachelor's degree in nursing or related field.

Registered Nurse (R.N.) licensure in the state of practice.

Requires skills and abilities normally acquired with two to three years of clinical experience and/or five years of experience as an RN Reviewer. Must be able to understand, apply and interpret complex case reviews and be able to work closely with our MDCC’s and others in a variety of settings.

Requires clinical knowledge, critical and analytical thinking skills to conduct compliance audits and draft reports. Computer skills in word processing and spreadsheets required. Ability to organize workload, manages multiple projects, and maintain confidentiality of all work information.

PREFERRED QUALIFICATIONS

Additional related education and/or experience preferred.

EEO Statement:

EEO/Female/Minority/Disability/Veterans

Our organization supports a drug-free work environment.

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