This position conducts scheduled audits defined in the annual audit plan, as well as, requested unplanned audits resulting from an internal request or a government investigation. Plans, coordinates and manages audits and third party investigations under the direction of compliance leadership. Conducts high level complex clinical, medical necessity, coding, billing and other business procedure audits and prepares and presents reports of findings at the direction of compliance leadership. Perform at a high level of expertise demonstrating comprehensive regulatory knowledge and project management skills. Acts as a liaison to operational and clinical departments regarding compliance regulatory issues. Assists with the development of corrective actions and monitoring activities to mitigate risk and validate ongoing compliance with government regulatory requirements. Conducts internal investigations reported though the compliance/ethics line as applicable, assists the organizations compliance officers as directed to research and investigate concerns or questions related to compliance or regulatory requirements. Provides support to compliance leadership during government investigations, including document indexing, medical record review, research regarding applicable laws and regulatory requirements, internal policies, procedures/operational processes and maintaining investigation file integrity.
Researches regulatory requirements relative to assigned audits and develops audit tools. Conducts audits utilizing defined audit standards, communicates the audit process through a pre-audit conference, identifies areas of potential risk, prepares audit reports, communicates results though an audit exit conference, assists in the development of corrective action plans, monitors effectiveness of corrective action plans, and provides training if indicated.
Manages highly complex and sensitive questions, concerns and complaints related to compliance matters, providing answers and support t system, divisional, regional and facility leadership. Ensures that reasonable steps are taken to respond timely and appropriately to compliance issues and concerns.
In consultation with others in the Compliance and Legal Departments, manages Banners response to governmental or other third-party audits, investigations or inquiries. Works with system-wide groups and committees to develop policies or processes to address identified issues.
Supports the system, division, regional or facility compliance management staff by responding to questions or concerns, researching matters of note, providing training as necessary and developing processes and procedures to remediate concerns or issues.
Maintains awareness of laws and regulations and conducts research as needed to identify applicable laws, regulations and practices to maintain compliance. Reviews related policies and procedures and literature. Communicates applicable compliance issues to the compliance officers and assists in the distribution of training of such changes. Stay knowledgeable on current compliance-related laws and regulations through personal initiative, seminars, training programs and peer contact.
Identifies training opportunities based on audits, designs and presents such education to prevent repeated compliance risks at the direction of the compliance leadership team. Provides compliance/documentation education sessions to physicians and other staff.
Coordinates external investigation efforts in conjunction with the Banner Legal Department and Compliance leadership. Maintains investigation integrity by managing investigation files, reviewing applicable laws and regulations, Banner internal policies and relative operational processes.
Assists the organization's compliance leadership, as directed, to research and investigate complaints, concerns or questions relative to compliance issues. Investigates and follows up on reported issues as directed. Assumes additional responsibilities to assist and support the organization's compliance program often dealing with complex and unique situations and problems.
Requires knowledge typically gained with completion of a bachelor's degree in business, nursing, internal audit or related field.
Requires skills and abilities normally acquired with significant payer, clinical or healthcare operations experience and/or experience in medical coding or audit experience within a complex care or payer environment. Must be able to understand, apply and interpret complex rules and regulatory requirements in a variety of payer or provider settings and relevant healthcare-related government regulations, including Medicare and Medicaid. Requires clinical or payer knowledge, critical and analytical thinking skills to conduct compliance audits and draft reports. Written and verbal communication skills required. Computer skills in word processing and spreadsheets required. Ability to organize workload, manage multiple projects, and maintain confidentiality of all work information.
Relevant certification based on assigned area of focus. Experience in Payer or Healthcare operations, regulatory requirements, legal, revenue cycle, coding registered nurse (RN) or audit standards preferred as relevant to the position.
Additional related education and/or experience preferred.
Internal Number: 213198
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.