This position provides an organized approach to the prevention, detection, and reporting of fraud, waste, and abuse. This position is primarily responsible for the analysis, auditing and monitoring activities related to the detection of fraud, waste, and abuse; and identifying potential problems. Understands key business objectives and health plan operations and assists with the follow-up and implementation of process and procedure improvements related to audit findings. Report findings to Operations Management to utilize for process improvement.
Performs data analysis of provider claims history to substantiate fraud and abuse allegations stemming from tips, subject matter experts, professional associates and other source of fraud, waste and abuse information.
Conduct independent & original research through both internal & external sources and databases.
Conduct initial assessment of incoming referrals, and complete related documentation.
Interact / coordinates activities with all levels of leadership on course of investigation or analytical plans.
Prepare accurate monthly, and ad-hoc management reports to detect and identify fraud trends, analysis of those trends and risk mitigation recommendations. Reports activities to management on a regular basis.
Designs and generates reports with trend analysis. Investigates and identifies unusual trends and causes. Generates and creates benchmarking results which may also include dashboard reporting.
Maintains working knowledge of AHCCCS and Medicare rules and regulations (must include knowledge of CPT, ICD-9, ICD-10 coding, HCPCS and DRGs)
Assist managerial staff in developing and maintaining specific work procedures, policies and procedures and process improvement projects.
Requires one to two years experience with health care claims required, two years auditing experience in an insurance and/or healthcare environment. Healthcare experience including AHCCCS / Medicare experience. Requires experience with process improvement projects and ability to plan/direct projects. Requires ability to pay attention to details and solid analytical, problem solving and organizational skills. Ability to analyze and trend data.
Proficient in Microsoft Office software (Word, Excel, Access, PowerPoint).
Certified Fraud Examiner (CFE) certification and Bachelor degree preferred.
Additional related education and/or experience preferred.
Internal Number: 257914
About Banner Health
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.