Primary City/State: Arizona, Arizona Department Name: BMA-D Work Shift: Day Job Category: Clinical Care The future is full of possibilities. At Banner Plans & Networks, we’re changing the industry to reduce healthcare costs while keeping members in optimal health. If you’re ready to change lives, we want to hear from you. Banner Plans & Networks (BPN) is an integrated network for Medicare 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 Registered Nurse RN Auditor, you will call upon your experience in auditing, quality and/or education to assist leadership with creating and completing quality audits. You will apply your clinical knowledge and auditing experience to provide education to RN Reviewers, Case Managers, Utilization Managers, and additional staff members. Your work location will be entirely remote. This salaried role does have the option of 4 10-hour shifts per week or 5 8-hour shifts per week. This role does not require weekends or a call rotation. Please note this role does require Arizona residency. If this role sounds like a wonderful new step in your career, 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 audits the organization's RN Reviews/Case Managers for adherence to established policies and guidelines surrounding case reviews for medical necessity. Uses critical thinking to audit clinical documentation confirming appropriate application of evidence based clinical criteria and proprietary tools and adherence to established productivity requirements. The position requires a sound knowledge of applicable regulations, including Medicare and Medicaid and has an understanding of our large commercial plans. Conducts telephonic audits, ensuring adherence to Banner’s Core Behaviors. CORE FUNCTIONS 1. Performs audits for inpatient and/or outpatient cases, procedural processes and other potential compliance risk areas. Audits medical records to monitor compliance ensuring adherence to established processes and workflows. Identifies areas of potential risk through audit processes, as well as assists with presentation of audit findings and design and monitoring of necessary corrective action. 2. Researches regulatory and medical necessity requirements and develops audit tools and report forms at the direction of the Care Management leadership. 3. Identifies training opportunities based on audits, designs and presents such education to prevent repeated compliance risks at the direction of the compliance leadership team. Provides compliance/documentation education sessions to Medical Directors of Care Coordination (MDCC) RN Reviewers, Case Managers and other staff. 4. Acts as a knowledge resource to the registration staff as to requirements for compliance with specific regulatory and accreditation requirements for federal, state and third party agencies. Pursues and participates in education to remain current with changes in the healthcare and insurance industries. As assigned, provides training for RN Reviewer/Case Management staff and other staff. 5. Assists the organization's compliance officers, as directed, to research and investigate complaints, concerns or questions relative to compliance issues. Investigates and follows up on reported issues as directed. 6. Maintains awareness of laws and regulations and conducts research as needed to identify applicable laws, regulations and practices to maintain compliance. Reviews related policies and procedures and literature. Communicates applicable medical necessity compliance issues to Care Management leadership and assists in the distribution of training of such changes. 7. Assumes additional responsibilities to assist and support the organization's compliance program often dealing with complex and unique situations and problems. 8. Performs job functions on a system-wide basis. Internal and external customers include, but are not limited to, executives and managers, compliance committees, physicians and clinical staff. MINIMUM QUALIFICATIONS Requires knowledge typically gained with completion of a bachelor's degree in nursing or related field. Registered Nurse (R.N.) licensure in the state of practice. Requires skills and abilities normally acquired with two to three years of clinical experience and/or five years of experience as an RN Reviewer. Must be able to understand, apply and interpret complex case reviews and be able to work closely with our MDCC’s and others in a variety of settings. Requires clinical knowledge, critical and analytical thinking skills to conduct compliance audits and draft reports. Computer skills in word processing and spreadsheets required. Ability to organize workload, manages multiple projects, and maintain confidentiality of all work information. PREFERRED QUALIFICATIONS Additional related education and/or experience preferred. EOE/Female/Minority/Disability/Veterans Our organization supports a drug-free work environment. Privacy Policy 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. We are proud to offer a comprehensive benefit package for all benefit-eligible positions. Please visit our Benefits Guide for more information. EEO/Female/Minority/Disability/Veterans Banner Health supports a drug-free work environment. Privacy Policy