This position is responsible for monitoring and auditing claim integrity submitted to government programs. Develops reports to monitor inpatient admissions to confirm medical necessity and patient status is supported by documentation in the electronic record. Research and analyze coding and billing data to confirm compliance with federal payer requirements, developing corrective actions as required. Coordinates all government data request for the compliance department related to coding, claims data, medical necessity and clinical documentation. Validate file and/or report integrity, perform trending analysis, identify discrepancies regarding coding, billing and patient stay accuracy.
Oversee ongoing proactive monthly claim review related to medical necessity, patient status, coding and general billing accuracy. Identifies documentation, coding and billing irregularities that could potentially result in an overpayment or other conditions of payment resulting in non-compliance with government payer requirements.
Develop data analytics reports which assist in monitoring coding and billing accuracy. Analyzes activity to help identify trends and inconsistencies to determine accuracy of claim submission. Prepare reports on monitoring activities and communicates results to appropriate parties on an ongoing basis or as assigned.
Interfaces with other departments to resolve outstanding/identified claim and/or documentation inconsistencies. Works with departments to determine root cause of inconsistency, assuming an active role in development and implementation of corrective action(s). Performs ongoing monitoring of corrective action implementation to validate solutions are effective.
Monitors data integrity related to coding and claim integrity to validate data elements comply with regulatory requirements. Assess activity results and conducts analyses of issues and/or trends. Reports identified issues to appropriate internal or external individuals for correction. Confirm claim correction process has occurred including required repayment of any overpayment incurred.
Manages federal payer and government agencies request for information including reporting, coding, claims data, medical necessity and clinical documentation. Validate file and/or report integrity, perform trending analysis, identify discrepancies regarding coding, billing and patient stay accuracy. Confirm documentation supports patient status and services provided and reimbursement.
Analyze internal and external reports to trend utilization and denial patterns compared to peers and CMS metrics. Develop exception reports and monitoring activities to identify potential risk to the organization and address deviations.
Remains current on coding and government regulations, communicates significant changes proactively leading change to implements compliant solutions to changes to regulatory or coding requirements.
Serves as a knowledge resource to leaders and staff regarding regulatory requirements. Completed special project and provides assistance and guidance as required.
Must possess a strong knowledge of business and/or health care compliance as normally obtained through the completion of a bachelors degree in business administration, accounting/finance, or health care related field.
Requires knowledge of laws and regulations pertaining to health care, regulatory compliance, Medicare/Medicaid and financial reimbursement systems.
Must possess strong planning skills and problem solving skills. Must possess strong oral and written communication skills to effectively interact with senior management team, physicians and federal and state governing bodies. Must also possess highly effective negotiation skills to communicate and interact with senior management team and physicians.
Master's degree and/or professional designations preferred. Previous health care or academic compliance, business or hospital system experience preferred.
Additional related education and/or experience preferred.
Internal Number: 211467
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.