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Banner Health believes leadership matters. We look for people who share our vision making health care easier, so life can be better. Our leaders are at the front of the health care transformation, planning the future of Banner Health.

As the Banner Health Network continues to grow, the role of Senior Director of Payment Integrity and Reimbursement will lead efforts in risk adjustment , e ncounters and claims recovery . In this highly visible role you will lead and execute strategic initiatives in alignment with organizational goals while ensuring compliance with state and federal regulatory requirements. You will have solid knowledge and experience in the insurance division with a specific focus in a Medicare plan. As a subject matter expert, you will review, prepare, analyze and present recommendations to the Banner Health Network executive leadership team to aid in decision-making. You will be an experienced leader with a proven track record in execution and influence at the highest level, as we are transforming as an organization in innovation.

Your pay and benefits are important components of your journey at Banner Health. This opportunity is also eligible for our Management Incentive Program, as part of your Total Rewards package. 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 leading the execution of payment integrity, strategy, risk adjustment and encounter submissions to CMS and the State for all of the Insurance Division. This role will be responsible for the execution of strategic initiatives, plans, and goals in alignment with organizational vision and goals. The candidate will engage in primary duties including operational planning and oversight, as well as resource, relationship, and people management. There will be direct operational payment integrity activities across the organization in support of all lines of business. Ensures payment integrity processes are in compliance with Federal and state regulatory and contractual requirements. This position will effectively use business intelligence and data analytics to monitor operations and identify cross functional process improvement opportunities.

This position will play a critical role in performance improvement, devising an approach for implementation, and managing deployment of risk adjustment activities and programs. This position is responsible for oversight of multi-year, large-scale RAF initiatives. The programs may be related to business process/technology migrations, process-design, program deployment and new initiatives related to RAF initiatives. The role will serve as a SME on Risk Adjustment, understanding the intricacies of the CMS Medicare model to drive effective strategies. The role will lead and work closely with the finance encounters team, HPIS encounters team, and claims team. This position is a key in the oversight of analyzing paid claim data completion to a successful encounter with the regulator. They are responsible for executive level report outs for financial impact related to encounters, oversight of the encounter program for Banner's Insurance Division, and working with leadership in a cross functional team to ensure financial viability. The role will direct and manage key processes including encounter data completion with the regulator to drive appropriate rate setting, risk adjustment accuracy, contract year risk band reconciliation, and reporting paid claims information to report/achieve health care measures. This position will establish processes and workflows to monitor the performance and assure all departments are delivering production to ensure complete and accurate paid claim data is encountered with CMS and the State.

CORE FUNCTIONS

1. Directs, supervises, and evaluates the work of direct staff and matrixed employees.

2. Participates into the development of the department budget to meet corporate goals and objectives. Meets annual budgetary goals. Translates organizational plans, goals, and initiatives into assumptions for annual operating and/or capital budgets. Negotiates contracts with external vendors for products and/or services and monitors/evaluates quality and/or performance.

3. Directs and participates in the development, implementation, and consistent application of effective organizational policies, procedures, and practices. Develops and supports internal controls to ensure that assets are safeguarded, policies and operating procedures are followed, necessary controls are effective and efficient, and compliance with current laws and regulations is achieved.

4. Reviews, prepares, analyzes, and presents reports and recommendations to senior leadership regarding operations, programs, services, and/or other applicable areas of interest in order to provide concise and accurate information that aids in decision-making.

MINIMUM QUALIFICATIONS

Bachelor's Degree in applicable field of Finance, Economics, Statistics, Mathematics, or Healthcare Administration.

Depending upon assigned area of responsibility, position may require applicable certifications and/or licensures, including but not limited to: RN; MD or DO; Driver's License; Certified Healthcare Protection Administrator (CHPA); Certified Protection Professional (CPP); Chartered Property Casualty Underwriter (CPCU); Associate in Risk Management (ARM); CPA; SPHR; Registered Health Information Administrator (RHIA); Registered Health Information Technologist (RHIT); Certified Healthcare Facility Manager (CHFM); Certified Facility Manager (CFM); Certified Coding Specialist (CCS); Certified Professional Coder (CPC); JD from an American Bar Association accredited school; admission to a State Bar Association.

Significant technical and managerial, typically gained through seven plus years relevant experience.

Ability to produce superior results in a financial performance-oriented environment. In depth understanding of claims processing, within a managed health care or health insurance business model.
Extensive knowledge of Medical, Behavioral Health, Dental and Pharmacy billing and coding. Detailed knowledge of Medicaid and Medicare requirements. Knowledge of managed care and health plan concepts, principles, practices and operations.
Proficient in developing operations KPI metrics.
Strong financial analysis and risk management skills.
Ability to take complex ideas and processes and communicate them in a clear and concise manner.

PREFERRED QUALIFICATIONS

Health Operations Experience. Payment Integrity, such as Claims Editing, Enrollment, Coordination of Benefits, Overpayment Identification, Claims Auditing, FWA, Risk Adjustment, Encounters.

Additional related education and/or experience preferred.