| Primary City/State: Tucson, Arizona Department Name: HP Statewide Finance Work Shift: Day Job Category: Administrative Services Great careers are built at Banner Health. There's more to health care than doctors and nurses. We support all staff members as they find the path that's right for them. Apply today, this could be the perfect opportunity for you. The Encounters Department is responsible for submitting all paid claims to the state Medicaid agency for future calculations of health plan rates and member assignments. Reinsurance and Transplant Representative will actively analyze and review medical claims and encounters partnering with finance, claims and encounter teams to ensure claims are paid correctly and reported to state Medicaid accurately and timely. 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 University Health Plans (BUHP) manage a variety of health plans. Our mission is to advance health and wellness through education, research and patient care. About Banner Health Banner Health is one of the largest, nonprofit health care systems in the country and the leading nonprofit provider of hospital services in all the communities we serve. Throughout our network of hospitals, primary care health centers, research centers, labs, physician practices and more, our skilled and compassionate professionals use the latest technology to make health care easier, so life can be better. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee. POSITION SUMMARY
The primary purpose of this position is to monitor submission and ensure collection of reimbursement for processed and paid claims that meet criteria for AHCCCS and other stop loss (AHCCCS reinsurance, AHCCCS catastrophic reinsurance, commercial stop loss) reimbursement and third party liability (TPL) claims. This position is also responsible for the monthly reporting of claim activity.
CORE FUNCTIONS
1. Produces, collects, and/or reviews reports or other information to identify paid claims that qualify as reimbursable cases for reinsurance, transplantation reimbursement, or TPL cases.
2. Maintains working knowledge and adheres to any reinsurance or transplantation reimbursement policy's benefits and submission requirements.
3. Maintains working knowledge and adheres to how to bill and collect for TPL claims. Adheres to government and industry guidelines in the preparation and collection of all cases.
4. Submits claims for all paid claim reimbursement (reinsurance), transplantation, or TPL cases in a timely and accurate manner.
5. Works with payers of all cases to reconcile any claims issues in a timely, accurate and professional manner. Provides the information and assistance necessary to the payers. Corresponds with outside payers. Follows up with the payer of all cases that are not collected in a timely manner. Ensures that collections are made when monies are due.
6. Works with payers of all cases to reconcile any claims issues in a timely, accurate and professional manner. Provides the information and assistance necessary to the payers. Corresponds with outside payers. Follows up with the payer of all cases that are not collected in a timely manner. Ensures that collections are made when monies are due.
7. Maintains accurate and complete individual files for all cases, which include documentation of all claims and follow-up activity for the case. Produces timely and accurate monthly reports that summarize the billing and collecting activity of all cases.
8. Reviews the AHCCCS Reinsurance System to identify pended claims and correct or coordinate the correction of the claims in a timely manner. Maintains paid claim reimbursement (reinsurance) desk top procedures manual and formal paid claims reimbursement (reinsurance) policies.
9. Works independently under limited supervision. Makes independent judgments based on specialized knowledge for accurate assignment of criteria/guidelines, and of billing and coding according to national guidelines. Confers with supervisor on any unusual situations. Internal customers: All levels of nursing management and staff, Medical Directors, and all other members of the interdisciplinary health care team, including Reimbursement Services, and HIMS. External customers: Physician and their office/clinic staff, delegated clients, patient/family.
MINIMUM QUALIFICATIONS
Must possess the knowledge typically gained from the completion of a Bachelor's degree in a business, finance or accounting field or the equivalent training and experience.
Requires the knowledge normally acquired over two or more years of experience in claims administration and management of reimbursement services. Must have demonstrated success in effective decision making in managing a diverse staff. Must possess knowledge of AHCCCS encounter regulations and guidelines. Ability to communicate effectively, both verbally and in writing. Requires an organized individual who can prioritize the workload to efficiently produce timely and accurate results under varying situations. Skills to manage significant amounts of electronic data through the use of a computerized office suite. Ability to communicate with AHCCCS technical and managerial personnel to identify system problems related to both procedures and programming.
PREFERRED QUALIFICATIONS
Familiarity with coordination of benefits and third party liability issues and reinsurance is preferred.
Additional related education and/or experience preferred. DATE APPROVED 06/7/2015 |
