Claims Audit Manager

Company: America's Health Insurance Plans (AHIP)
Location: Olympia
Posted on: October 8, 2020

Job Description:

Primary City/State: Phoenix, Arizona Department Name: Claims Processing Work Shift: Day Job Category: General Operations Good health care is key to a good life. At Banner Health, we understand that, and that's why we work hard every day to make a difference in people's lives. We've united under a common goal: Make health care easier, so life can be better. It's a lofty goal, but it's one we're committed to seeing through. Do you like the idea of making a positive change in people's lives - and your own? If so, this could be the perfect opportunity for you. Apply now.BPA Reimbursement Services is responsible for claims processing, adjustments, refunds, reconsiderations, projects, incoming checks and cash, eligibility and claims funding for BHN. There is also a responsibility for the oversight of the BCBS Advantage reimbursement, adjustments and refund processes.As a Claims Auditor Manager you will manage the daily auditing functions for all Banner product lines to include Medicare, Medicaid, Commercial, self-insured, risk plan, and third party administrator related activity. You will be responsible for day-to-day department functions, including staff placement, training, supervision and productivity for all auditing processes, including focus audits, plan audits data entry and reporting. Monitoring claims data looking for possible fraudulent billing from providers, support claim system coding, provider contract language and assist with general provider billing question. Training will be in the Phoenix or Mesa, AZ offices, after training the position will be remote with occasional in office meetings.Your pay and benefits are important components of your journey at Banner Health. Banner Health offers a variety of benefits to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life. 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 This position supervises the daily auditing functions for all Banner product lines to include Medicare, Medicaid, Commercial, self-insured, risk plan, and third party administrator related activity. Responsible for day-to-day department functions, including staff placement, training, supervision and productivity for all auditing processes, including focus audits, plan audits data entry and reporting. CORE FUNCTIONS 1. Supervises human and material resources and work activities in the day-to-day operations of assigned area for all auditing functions and all lines of business to ensure staff are maintaining performance at a level that meets or exceeds department standards. 2. Hires, trains, and supervises the department staff. Provides leadership, coaching, recognition, and conducts corrective action and performance evaluations. Establishes priorities, workloads, schedules, controls and work procedures 3. Supervises and coordinates proper maintenance of all on internal records associated with the department's management information and claims payment system. 4. Provides resources and information to the claims staff that will allow for correct and timely adjudication of all provider and member claims. Maintains a thorough and current knowledge of the Summary Plans Descriptions for each health plan serviced. 5. Monitors and reports on work performance against established criteria related to claims accuracy and provider payment requirements. 6. Works independently under general supervision. Has freedom to determine how to best accomplish functions within established procedures. Confers with manager on any unusual situations. Internal customers may include medical staff, network personnel and organization senior management. External customers may include physicians and their office staff, payors, provider networks, regulatory agencies and vendors. MINIMUM QUALIFICATIONS Knowledge as normally obtained through the completion of a bachelor's degree or equivalent work experience. Requires 3 or more years of experience in reimbursement, claims and related systems, provider contract interpretation, system development and previous experience with leadership position demonstrating effective communication with employees, providers, vendors and customers. Must have a strong knowledge and understanding of managed care, commercial insurance, Medicaid, and CMS reimbursement methodologies. Must demonstrate a track record of effective and mature decision making in managing a diverse staff. PREFERRED QUALIFICATIONS Additional related education and/or experience preferred. Previous lead or supervisory experience Additional related education and/or experience preferred. DATE APPROVED 04/08/2018Internal Number: R4239

Keywords: America's Health Insurance Plans (AHIP), Olympia , Claims Audit Manager, Other , Olympia, Washington