This position reviews clinical information and conducts audits of billings to determine appropriateness of charges in accordance with contracted payor terms, standards of care and insurance policy parameters. Works with physicians, patients, payors and other healthcare providers support appropriate utilization of healthcare services. Provides clinical knowledge to assist billing and collection team members in responding to insurance denial of billings.
Evaluates and intervenes concurrently and retrospectively for level of care, coverage issues, payor outliers, split billing, disallowed charges, patient inquires, denial and compliance issues.
Initiates actions and participates with Patient Financial Services payor teams regarding resolution of denial management issues or compliance issues. Works with authorized payors or reviewers to resolve denial management issues, reconsiderations and appeals.
Tracks, monitors and documents denial causes and resolutions with appropriate management staff.
Acts as a knowledge resource for billing staff members. Identifies educational needs regarding payor issues, functions as preceptor, and provides appropriate education.
Builds and continually updates a knowledge of Third Party Payor requirements for covered treatment protocols by diagnosis, approval requirements for procedures, and coverage norms.
Provides education by collaborating with Care Coordination at company facilities or other staff of non-company locations on concurrent and retrospective utilization review. Accurately and thoroughly completes documentation required for claims payment of services approved through concurrent review and case management.
Requires Registered Nurse (R.N.) licensure in the state of practice. In a Behavioral Health setting requires Registered Nurse (R.N.) licensure in the state of practice or a current Arizona Board of Behavioral Health Examiners License based on an accredited Master's degree.
Requires five or more years of clinical nursing or related experience or, in a Behavioral Health setting, Master's level Social Work in healthcare, behavioral health counseling, or related experience. Experience in evaluation techniques, teaching, hospital operations, reimbursement methods, medical staff relations, and the charging/billing process is required. A working knowledge of utilization management and patient services is required. A working knowledge of Medical and third party payor requirements and reimbursement methodologies is required.
Highly developed human relation and communication skills are required. Excellent organizational, written and verbal communication skills are essential for this position.
A Bachelor of Science degree in Nursing is preferred.
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.