Heath Plan Compliance Auditor

Department Name:

Compliance

Work Shift:

Day

Job Category:

General Operations

Estimated Pay Range:

$27.72 - $46.20 / hour, based on location, education, & experience.

In accordance with State Pay Transparency Rules.

Great careers are built at Banner Health. We’re looking for the best and brightest to join our team that earned Great Place to Work® Certification™.  Apply today to build your career.

Banner Plans & Networks (BPN) is an integrated network for Medicare, Medicaid, and private health plans. Known nationally as an innovative leader, BPN insurance plans and physicians work collaboratively to keep members in optimal health while reducing costs. Supporting our members and vast network of providers is a team of professionals known for innovation, collaboration, and teamwork. If you would like to contribute to this leading-edge work, we invite you to bring your experience and skills to BPN.

As a Health Plan Compliance Auditor, your primary responsibility is to conduct audits by comparing provider medical record documentation to claims submitted in the BPN claims system, ensuring that the documentation supports the billed services. This role involves reviewing medical records, analyzing claim data, and verifying compliance with applicable guidelines. You will also be responsible for creating detailed audit spreadsheets, drafting audit summaries and formal letters, logging audit findings, requesting necessary records from providers, developing audit schedules, and following up to ensure timely responses and resolution. Accuracy, organization, and clear communication are essential to successfully fulfill the duties of this position.

Required Qualifications:

This role requires candidates to hold either the Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) credentials, issued by either AAPC or AHIMA.

4+ years of experience in claims processing, billing, or healthcare compliance.

4+ years of experience in managed care or health care experience

Knowledge of Medicare/Medicaid regulations

Experience working with Arizona Health Care Cost Containment System (AHCCCS)

Strong analytical and investigative skills

Excellent communication skills for member and provider interactions.

This Health Plan Compliance Auditor position is primarily remote, with occasional local travel to physician offices as needed. Arizona residency is required to meet compliance regulations. Work hours are Monday through Friday, consisting of eight-hour shifts with some flexibility in start and end times. If you're seeking a rewarding opportunity that offers both flexibility and purpose, we encourage you to apply today!

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 ensures compliance through auditing and monitoring of operational areas (policy and procedures) and regulatory requirements of the health plan. This position works both independently and collaboratively with all health plan functional areas to develop, implement, maintain and evaluate contractually compliant operational practices. Report findings to Operations Management to utilize for process improvement. Develop training programs for managed care staff based on audit findings and regulatory guidance.

CORE FUNCTIONS
1. Maintains working knowledge of AHCCCS and Medicare rules and regulations (may also include knowledge of CPT, ICD-9 coding, HCPCS and DRGs). Researches regulatory requirements and develop/update audit tools to evaluate health plan compliance against regulatory requirements. Utilizes resources such as payment guidelines, AHCCCS AMPM and other resources as they impacts departments.

2. Develops, conducts and documents specialized audits as needed and as requested. Audits specified operational areas as identified and documented in the Audit Plan within the health plan (such as claims, system analysts and referral coordinators). Prepares audit summary documents and report and benchmark results of audits to the Compliance Department management team. Validates implemented Corrective Action Plans (CAPs) to ensure assigned functional areas are performing in a compliant manner.

3. Meets with assigned functional area management team to communicate audit activities and outcomes of assigned audits. Effectively articulate government requirements to all levels of staff. Assists managerial staff in developing and maintaining specific work procedures, policies and procedures and process improvement projects.

4. Conducts varied assignments and investigations, performs and analyzes systems, and assists the Compliance management team to update the annual Audit Work Plan. Develops individual and group training programs and materials based on need indicated from audit and updated policies and procedures.

5. Under general direction, assists in the analysis of the company's regulatory compliance posture and the development of control recommendations. Consults with product management, claims and sales management to keep abreast of functional area changes. Reviews recent proposed activities by regulatory agencies to determine potential impact on company operations. Perform in-depth analysis of regulatory changes and ensure assigned functional areas are implementing/revising processes to be in compliance with program requirements. Participate in functional area work groups to implement compliant processes. Develop desktops to support day-to-day activities.

6. Assists with the analysis and interpretation of regulatory compliance requirements especially as they relate to the Health Plans and assigned functional areas. Understands and monitors assigned functional areas compliance metrics (e.g., dashboards) to determine whether assigned functional areas may be at risk for non-compliance with government requirements. Conducts detailed analyses of assigned functional areas to ensure in-depth understanding of all functional area requirements.

7. Assists Compliance Manager in monitoring and reviewing regulatory and legislative changes, preparing company’s response to regulatory changes and following up with appropriate areas to ensure required changes are implemented.

8. The scope of this position is broad both in clientele (entire health plan work force) and in topical areas that need to be addressed (laws and regulations that are within the scope of health plan compliance). Represents compliance when participating on committees and in work groups. The position must engage in conducting highly confidential work and ensuring compliance with managed care regulations. The position will be required to work cooperatively with a variety of departments.

MINIMUM QUALIFICATIONS

Two to four years of auditing/training experience in an insurance and/or healthcare environment and four to six years managed care or health care experience required.

In-depth knowledge and experience with AHCCCS and Medicare. Applicable experience in various functional areas of health plan/health care operations, such as Finance, Information Systems, Network Development, Member Service, Marketing and Enrollment. Knowledge of Encounters, TPL, and Reinsurance. Understanding of accounting principles and procedures, knowledge of Electronic Transactions, HIPAA, IDX and other related systems. Customer Service background, ACD and telephone standards knowledge. Grievance and Appeals background. In-depth knowledge of contracts, credentialing and re-credentialing processes, understanding and knowledge of Medicare standards for sales and enrollment.

Must have an exemplary background in maintaining confidentiality and handling sensitive information. Ability to interpret complex regulatory requirements and proven ability to build relationships and interface with people in a positive manner. Strong working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint) and strong organizational/analytical, written and verbal communication skills. Requires professional knowledge of the theories, practices, methods, and techniques of auditing to plan. Excellent customer service skills, both internal and external and the ability to work independently.

PREFERRED QUALIFICATIONS

College coursework, degree or related work experience is preferred. IDX experience preferred.

Additional related education and/or experience preferred.

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