Nurse Reviewer

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Great careers are built at Banner. We understand that talented professionals appreciate having options. We are proud to offer our team members many career and lifestyle choices including remote & hybrid work options. Apply today.

Banner Plans & Networks (BPN) is a nationally recognized healthcare leader that integrates Medicare and private health plans. Our main goal is to reduce healthcare costs while keeping our members in optimal health. BPN is known for its innovative, collaborative, and team-oriented approach to healthcare. We offer diverse career opportunities, from entry-level to leadership positions, and extend our innovation to employment settings by including remote and hybrid opportunities.

As a Registered Nurse Reviewer, you will work a critical part of the Banner Plans & Networks Team. You will call on your experience as a Registered Nurse and your knowledge of Case Managment and Utilization Management to review clinical records to ensure patients are in the correct status.

Your work location will be entirely remote. You will work 4 x 10-hour shifts per week and every third weekend. Shift availability is days and mid shifts. Details to be discussed during the interview process. Please note this position does require four holidays a year and you will be provided that information by February of each year. If this role sounds like the one for you, apply today!

POSITION SUMMARY
This position reviews clinical information and conducts audits of billings to determine appropriateness of charges in accordance with contracted payor terms, standards of care and insurance policy parameters. Works with physicians, patients, payors and other healthcare providers support appropriate utilization of healthcare services. Provides clinical knowledge to assist billing and collection team members in responding to insurance denial of billings.

CORE FUNCTIONS
1. Evaluates and intervenes concurrently and retrospectively for level of care, coverage issues, payor outliers, split billing, disallowed charges, patient inquires, denial and compliance issues.

2. Initiates actions and participates with Patient Financial Services payor teams regarding resolution of denial management issues or compliance issues. Works with authorized payors or reviewers to resolve denial management issues, reconsiderations and appeals.

3. Tracks, monitors and documents denial causes and resolutions with appropriate management staff.

4. Acts as a knowledge resource for billing staff members. Identifies educational needs regarding payor issues, functions as preceptor, and provides appropriate education.

5. Builds and continually updates a knowledge of Third Party Payor requirements for covered treatment protocols by diagnosis, approval requirements for procedures, and coverage norms.

6. Provides education by collaborating with Care Coordination at company facilities or other staff of non-company locations on concurrent and retrospective utilization review. Accurately and thoroughly completes documentation required for claims payment of services approved through concurrent review and case management.

7. Works independently under limited supervision. Makes independent judgments based on specialized knowledge. Holds Facility or Regional responsibility for audited and denied billing issues. Internal customers: Patient/family, medical staff, case managers, nursing, social workers, patient services/placement/finances/audit, emergency department, clinic and all other departments and ancillary/support services. External customers: Medical Directors/payors/reviewers, contracted review agencies, other facilities/services, physician’s offices.

MINIMUM QUALIFICATIONS
Requires Registered Nurse (R.N.) licensure in the state of practice. In a Behavioral Health setting requires Registered Nurse (R.N.) licensure in the state of practice or a current Arizona Board of Behavioral Health Examiners License based on an accredited Master's degree.

Requires five or more years of clinical nursing or related experience or, in a Behavioral Health setting, Master's level Social Work in healthcare, behavioral health counseling, or related experience. Experience in evaluation techniques, teaching, hospital operations, reimbursement methods, medical staff relations, and the charging/billing process is required. A working knowledge of utilization management and patient services is required. A working knowledge of Medical and third-party payor requirements and reimbursement methodologies is required.

Employees working at BUMG, BUMCT, or BUMCS in a Behavioral Health clinical setting that serves children must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment. Employees working at Banner Behavioral Health Hospital or BTMC Behavioral must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment. Employees working in the Banner McKee Senior Behavioral Health Inpatient Unit must possess a Colorado Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment. Employees working in any Banner Staffing (BSS) Behavioral Health role in Arizona must possess a State of Arizona Department of Public Safety Level One Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment.

Highly developed human relation and communication skills are required. Excellent organizational, written and verbal communication skills are essential for this position.

PREFERRED QUALIFICATIONS

A Bachelor of Science degree in Nursing is preferred.

Additional related education and/or experience preferred.

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