This position will review operations/claims department issues for correct coding along with referral (prior authorization) issues Review criteria are based on Medicaid, CMS (Centers for Medicare/Medicaid) and established clinical guidelines. This position will assist in identifying reimbursement over/under payment outcomes and represent Claims and Reimbursement Services in claim reviews to facilitate payments.
Reviews claims for correct coding based on HP guidelines that also include Medicaid, Commercial, CMS regulations and CCI principles. Records and communicates all review outcomes.
Provides recommendations regarding incorrect reimbursements based on business decisions and correct coding guidelines
Identifies opportunities for improving the authorization process
Reviews, researches and provides identification of regulatory and accepted practices to determine any potential impact to providers, members, and Health Network operations.
Works directly with operations and authorization personnel in the claim review process.
Participates in required in-services by the Health Network or the department. Represents department at assigned meetings.
Assists leadership and oversight entities including regulators and internal compliance, fraud, waste and abuse designees in identifying, measuring and meeting regulatory expectations and financial goals.
Assists leadership in training Banner Health Network in regard to correct coding, fraud waste and abuse where applicable while utilizing appropriate training based communication.
Must possess a strong knowledge of clinical care as normally obtained through the completion of an Associates in a healthcare related field.
Requires Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician (CCS-P) or Registered Health Information Technologist (RHIT) or Registered Health Information Administration (RHIA) in an active status with the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC).
Must have the ability to work independently, possess demonstrated critical thinking skills, problem-solving abilities, and effective communication skills and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.