| Primary City/State: Tucson, Arizona Department Name: Claims Processing Work Shift: Day Job Category: Legal 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
The primary purpose of this position, under the direction of the Claims Systems Manager, is to validate provider contracts and ensure that Claims payments support the contract term. In addition, the incumbent will provide support to the Health Plans Claims Department through complex operational and systems analysis.
CORE FUNCTIONS
1. Audits Contracts entered into the claims system to ensure that Claims are paying per the Contract Terms; Analyzes Claims Data to identify front end solutions to rectify ongoing issues. Explains the underlying drivers of the claims resubmission data to identify trends.
2. Identifies process improvement needs and actively participate in system/claim projects based upon data analysis performed. Reviews reports and data analysis to support the Claims Department decision-making.
3. Translates provider disputes and refund data reporting requirements into data logic to create mapping documents to support the successful submission of IT system intake documents to build claim system logic to support contract requirements Provides data support for Claims review, Provider Data Management Grievance & Appeals review, Provider Relations, PEC, Finance and Contracting.
4. Provides reporting support for leadership or their designees. Collaborates with appropriate departments responsible for contract implementation and oversight/maintenance to assist with system configuration and reporting. Collaborates with relevant personnel to design and develop reports detailing compliance with regulatory requirements using new and/or existing software systems. Facilitates cross-functional teams and/or leads projects to implement system or policy changes, determine policies and manage process improvement and redesign.
5. Provides recommendations for system modifications to meet and or exceed legislative requirements. Monitors and evaluates opportunities for technical innovations and enhancements for the Claims Department.
6. Collaborates with Health Plan Trainer or designees to develop and write policies relevant to data analytics and data deliverable compliance requirements for Claims. Supports all affected departments by providing training and education as required to ensure claim system setup is compliant with health plan and CMS requirements.
7. This position works under supervision, prioritizing data from multiple sources to provide quality care and support. Incumbents work in a fast-paced, sometimes stressful environment with a strong focus on customer service. Interacts with staff at all levels throughout the organization.
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
NOTE: The core functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.
SUPERVISORY RESPONSIBILITIES
DIRECTLY REPORTING
None
MATRIX OR INDIRECT REPORTING
None
TYPE OF SUPERVISORY RESPONSIBILITIES
N/A
Banner Health Leadership will strive to uphold the mission, values, and purpose of the organization. They will serve as role models for staff and act in a people-centered, service excellence-focused, and results-oriented manner.
PHYSICAL DEMANDS/ENVIRONMENT FACTORS
OE - Typical Office Environment: (Accountant, Administrative Assistant, Consultant, Program Manager)
Requires extensive sitting with periodic standing and walking.
May be required to lift up to 20 pounds.
Requires significant use of personal computer, phone and general office equipment.
Needs adequate visual acuity, ability to grasp and handle objects.
Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
May require off-site travel
MINIMUM QUALIFICATIONS
Knowledge, skills and abilities as normally obtained through the completion of a bachelor's degree or equivalent combination of work experience and/or education in health care administration/management and/or finance administration or related field.
Four to five years of related experience required. Requires a high level of skill in Microsoft Excel, Microsoft Access, database/report writing software, and understanding complex contracts and managed care information systems.
Requires personal skills and abilities include the ability to adapt to changes, work independently and as a member of a work group, communicate effectively, maintain accuracy, meet deadlines, work in a fast paced environment, proactively analyze and solve problems, ensure accuracy in all tasks, pay close attention to detail, prioritize multiple tasks and remain organized.
PREFERRED QUALIFICATIONS
Preferred skills include an understanding of medical billing, coding, claims payment processes, and reimbursement management, as well as experience in IDX and/or Oracle SQL, impact claim system, share point, and other applications as deemed necessary for line of business
Additional related education and/or experience preferred. DATE APPROVED 04/08/2018 |
