This position audits all claims for proper adjudication while handling special projects, reconsiderations, refunds and void processes. The incumbent will maintain proper record keeping of all support files and be responsible for providing in-service to appropriate personnel with regard to changes and updates in claims processing guidelines for the Banner and Risk Plans. This position may also be responsible for resolution of issues received from internal/external clients to include Customer Service, Provider Relations, Networks, Finance, Medical Management, etc.
Audits claims for accuracy of the data, payments, contract interpretation and compliance within established polices and procedures. Researches and processes adjustments for reconsiderations, refunds, voids, and special projects.
Selects claims though random process to conduct audits to ensure compliance standards is met. Supports and assists with mass adjustment projects.
Manages the claims administration workflow in a timely and accurate manner necessary to meet Plan requirements associated with the company Health, Risk and Dental Plan benefit process and/or requirements associated with AHCCCS, Medicare, and Commercial.
Acts as the primary claims resolution specialist for internal and external clients related to escalated claims issues and for claims adjudication and handling of difficult claims issues.
Provides information to providers/members and maintains system information as necessary for internal and external auditing purposes.
Develops and creates reports necessary to track, trend and monitor for training and quality purposes, and workflow efficiencies.
High school diploma/GED or equivalent working knowledge.
A minimum of three to four years experience in Medical and/or Dental claims adjudication in an automated environment. Must have an excellent understanding of medical terminology, contract and benefit interpretation, CPT, HCPCS and ICD-9/ICD-10 coding with a working knowledge of Medicare, AHCCCS, Self-funded and/or commercial insurance plans.
Must possess strong oral and written communication skills including effective interpersonal skills and attention to detail and accuracy.
Previous claims auditing experience is preferred, Associates degree in related field.
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.