Program Manager, Payment Integrity and Reimbursement

Primary City/State:

Tucson, Arizona

Department Name:

Fiscal Services

Work Shift:

Day

Job Category:

General Operations

Great careers are built at Banner Health. We understand that talented professionals appreciate having options. We are proud to offer our team members many career and lifestyle choices including remote work options. Apply today, this could be the perfect opportunity for you.

Tucson is set in a Sonoran Desert valley surrounded by five mountain ranges. Boasting an average 350 sunny days a year and warm dry air, the climate is ideal for year-round outdoor recreation. Tucson offers one-of-a-kind experiences for those interested in outdoor adventure and nature, heritage and culture, arts and attractions, golf and original Southwest-inspired dining.

In this role of Program Manager, Payment Integrity & Reimbursement your responsibilities will vary day to day depending on the business need. You will train staff on systems usage or claim/encounter knowledge. You will also research encounters within the state's PMMIS, work with a value based contract like United Healthcare and Finthrive on risk adjustable encounter submission omissions, and/or work with our Medicare DSNP, HMO, PPO plans drilling into claim errors impacting encounters. You will follow regulatory guidelines requesting approval for claims recoupments. and support a regulatory audit around data validation. This role fills a gap in supporting all payment integrity special projects, research, training and testing. The schedule for this remote position are standard Business hours Monday-Friday 8AM-5PM and may require some flex time outside of those hours for special projects, regulatory deadlines, etc. The team meets on-site quarterly in Tucson, AZ.

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 is responsible for supporting the Payment Integrity & Reimbursement Team, ensuring the processing of complicated encounter issues is integrated into transplants, reinsurance, claims recovery and risk adjustment processes to ensure greater revenue integrity for Banner Health Plans and delegated entities. This position provides leadership recommendations for development/maintenance/updates as necessary to ensure compliance with Medicare/Medicaid encounter submission requirements as well as impacts from transplants, reinsurance, risk adjustment and claims recoveries, including testing and training of initiatives. Serves as a resource for personnel for all Medicare/Medicaid payment integrity issues related to encounters to drive improved revenue integrity.

CORE FUNCTIONS

1. Subject matter expert for Medicaid and Medicare Payment Integrity encounter processes impacting all claims, transplants, reinsurance, claims recovery and risk adjustment processes to ensure greater revenue integrity for Banner Health Plans and delegated entities. Partners with Payment Integrity leadership team to develop programs to improve/enhance the effectiveness of various payment integrity programs impacted by claims processing and encounter submission/accuracy processes.

2. Acts as tester of new and enhanced processes, as well as acting as the liaison with IT and vendor partners. Maintains and implements new regulatory policies related to payment integrity and encounters and cross trains teams to ensure implementation of new requirements. Provides high level expertise to the development of fully integrated testing scenarios. Ensures that the information systems across multiple levels and lines of business and their relationships are considered and are part of the comprehensive testing plans.

3. Identifies issues/errors impacting encounter vendor(s) and performance related to issues/errors. Pro-actively works with vendor and internal team to provide solutions to quickly remediate the issue/error to help avoid delays in processing and vendor standing.

4. Supports analysis of complicated encounter processing issues through analysis of encounter data, transplants, reinsurance cases, risk adjustment related encounter impact, and claims recovery encounter projects for potential system updates/issues coordinating with the Encounters Director. Brings strength in logic and analysis of data, sorts through data and determines which elements are useful or pertinent to the assigned project. Identifies outliers, system/application errors, and recognizes trends; then, presents data and analysis results to appropriate parties ensuring the solutions are timely and of acceptable quality.

5. Responsible for coordination of AHCCCS ACOM 412 policy with Claims department, Claims Recovery and Encounters departments. Includes tracking of all Medicaid recoveries and recoupments following AHCCCS guidelines as well as working with government programs for approval. Coordinates communication with providers upon AHCCCS approval. Includes responsibility for maintain policies and procedures around this topic.

6. Supports and designs end user training and curriculum for applications and systems, from observations in research and from new programmatic changes from regulatory bodies relating to payment integrity encounters and encounter vendors from dental to pharmacy to encounter processing. Facilitates the initial rollout and ongoing training of the user community. Review/write requirements; perform testing and post-production validation, act as liaison between business units, payment integrity vendors and IT, and communicate system and process changes to the business areas.

7. Responsible for payment integrity coordination and responding to Medicaid Annual Data Validation Audit and any applicable audits from CMS/Medicaid. Pro-actively works internally and with vendors to avoid regulatory sanctions and penalties due to errors/audit findings.

8. Maintains current professional and technical knowledge relating to the healthcare industry by attending educational workshops/conferences, establishing personal networks, and/or maintaining relevant certification or licensure as business needs require. Ensures that department and company standards are implemented and consistently adhered.

9. Work is performed in a fast-paced multi-tasked environment where there may be conflicting priorities or tight deadlines. The incumbent has decision-making authority within established guidelines for projects and applications and is expected to ask for guidance for more complex or non-standard situations. Expected to work at peer level across diverse areas and multiple states. The incumbent participates in meetings, presentations, visioning sessions, strategic and planning sessions, implementation activities, and supports functions company-wide.

MINIMUM QUALIFICATIONS

Bachelor's degree or equivalent working knowledge in business, finance, economics, math, health care or related field.

Certification for CPC (Certified Professional Coder).

Significant experience, typically gained through four plus years relevant experience.

Must demonstrate general knowledge claims/encounters, CMS, and Medicaid reimbursement. Needs experience in project planning and reporting, either individual or team. Requires skills to engage technical and non-technical audiences. Incumbent will have skills to mentor less experienced team. Must be able to work with minimal supervision and prioritize multiple projects. Requires ability to effectively interact and communicate both verbally and in writing through curriculum, staff training, and presentations to leadership. Proven advanced, analytical, and modeling skills are necessary, including advance Microsoft Excel skills. Must be proficient in the use of sophisticated software programs.

PREFERRED QUALIFICATIONS

MBA, Masters Business Administration preferred.

Additional related education and/or experience preferred.

EOE/Female/Minority/Disability/Veterans

Our organization supports a drug-free work environment.

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