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The Population Health Service Operations medical claims review department employs seasoned clinicians to independently evaluate medical claims and associated records by applying advanced clinical knowledge. Team members apply medically appropriate guidelines and other appropriate criteria to make determinations on appropriate care and coverage of clinical services. This is a unique opportunity to utilize clinical skills and experience in an autonomous fashion while still having support from team leadership and medical director guidance. "Work for someone that believes in you" "If you have a strong clinical and analytical background, as well as a spirit for innovation, Banner Health is where you can make a dramatic difference in clinical customer service.
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 is responsible for reviewing content of the medical record and assisting in the clarification of any documentation ambiguities noted. This position is a member of the clinical team and acts as a consultant/subject matter expert to facility staff and Providers related to medical record clinical documentation requirement to ensure the overall completeness, compliance and specificity of Provider documentation exists. This position is responsible for identifying and capturing additional revenue opportunities and will also be the documentation liaison for the facility between acute care coding and Providers.
CORE FUNCTIONS 1. Provides subject matter expertise related to DRG, clinical documentation opportunities and requirements. Serves as an essential member of the clinical team, emphasizing their role in reviewing content of the medical record, assisting in the clarification of documentation ambiguities. Serves as the liaison between acute care coding and Providers to explain, educate and assist in the needed documentation requirements to accurate conversion from the "clinical language" to the needed "coding language" in order to capture revenue.
2. Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software. Utilizes available resources to formulate clinically credible "documentation clarification questions" for members of the clinical team aimed at improving the accuracy of the documentation process which is followed by effective and appropriate communication with Providers and timely follow up on all cases.
3. Ensures data integrity of the clinical documentation database through compliant, accurate and appropriate entries, which include but is not limited to, accurate input of case data, correct assignment of documentation clarification types and Provider responses, and ensuring precise case reconciliation with correct DRG shifts recorded.
4. Ensures the accuracy and completeness of clinical information used for measuring and reporting Provider and facility outcomes (coding assignments, HAC, quality of care, facility and system initiatives) while facilitating HIMS dept compliance of time requirements for coding and billing revenue cycle.
5. Educates customers through presentations and/or reports for clinicians and facility management on clinical documentation opportunities, acute care coding and reimbursement issues, as well as performance improvement methodologies.
6. Serves as member of facility task force meetings, and as requested attends facility steering committee meetings and/or other facility meetings.
7. This position works independently in a "hybrid" work mode - working both in-facility as well as remotely and has multi-facility/entity responsibility, with no direct budgetary oversight. This position is a member of the clinical team ensuring accuracy and compliance with acute care coding assignments, POA status, HAC, quality of care, supports specific Hospital and System initiatives, and aids HIMS Dept in meeting their time requirement of the coding and billing revenue cycle. Extensive interaction with Providers, HIMS professionals, nursing and other ancillary staff. Internal Interactions: All levels of nursing management and staff, medical staff, Providers and all other members of the interdisciplinary health care team. External Interactions: Physicians and their office staff.
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
MINIMUM QUALIFICATIONS Must possess a strong knowledge of clinical care as normally obtained through the completion of a bachelor's degree in nursing.
Requires Registered Nurse (R.N.) license in state worked.
Requires two to four years of recent acute care experience either in a Hospital or Surgical setting. Must have the ability to interface with multiple software applications, work independently, possess demonstrated critical thinking skills, problem-solving abilities, communication and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format.
PREFERRED QUALIFICATIONS Experience with acute clinical documentation programs/ u tilization management/prior authorization/coding experience .
Additional related education and/or experience preferred.
Internal Number: R25067
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.