**Primary City/State:** Arizona, Arizona **Department Name:** CRU **Work Shift:** Day **Job Category:** General Operations 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. Recognized nationally as an innovative leader in health care, Banner Plans & Networks (BPN) integrates Medicare and private health plans to reduce healthcare costs while keeping our members in optimal health. Known for our innovative, collaborative, and team-oriented approach, BPN offers a variety of career opportunities and innovative employment options by offering remote and hybrid work settings. As a Director, Claims Recovery Unit, you will lead a small team and support three vendors. You will primarily monitor Banner Plans & Networks claims payments for accuracy, actively identify deficiencies of incorrect payments, and work with vendors to remediate and correct payment discrepancies to ensure plan fiscal responsibility. You will call upon your **leadership experience and** **requir** **ed work experience in medical billing and/or medical coding,** as you manage multiple projects, collaborate with varied teams within and outside of BPN, and problem solve for solutions on a daily basis. Your work location will be entirely remote and will require quarterly onsite meetings in Phoenix and Tucson. Your work schedule with be Monday-Friday working within the Arizona Time Zone. If this role sounds like the one for you apply today. Your pay and benefits are important components of your journey at Banner Health. This opportunity includes the option to participate in a variety of health, financial, and security benefits. In addition, this position may be eligible for our Management Incentive Program as part of your Total Rewards package. 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 the development, oversight, discovery, and recovery of claim overpayments. The Claims Recovery Unit (CRU) is designed to help reduce medical costs of pre and post payment claims by identifying billing errors, coding errors, deficient clinical documentation to support a submitted claim and appropriate pricing for excessive billed charges. The position is responsible for managing external vendors and internal recoupment processes in data mining, MS and APR DRG recovery, and TPL recoveries. This position works closely with IT to implement claims systems edits to reduce overpayments and increase claims auto adjudication. Lastly, this position provides support as a clinical coding expert for HCFA 1500 and UB-04 claims utilizing nationally accepted coding guidelines for Medicare and Medicaid. CORE FUNCTIONS 1. Manages professional staff through ongoing training, development, and the Banner ONE TEAM culture. Hires, develops, and motivates employees to achieve claims recovery objectives while coordinating tasks in a complex matrix environment partnering with IT, Claims, Encounters, Medical Management, FWA, G&A, Network, Analytics, and other departments. 2. Responsible for CRU Vendor oversight and performance success of all recovery activities related to Data Mining, MS and APR DRG, and TPL. Responsible for. implementation and effectiveness of workflows from finding a recovery opportunity to ensuring the claims team follows through with recovery find. Includes responsibilities of vendor invoice accuracy and timeliness. 3. Develops and maintains departmental plans, desktops and policies to maintain compliance with regulatory partners and ensure organizational priorities. 4. Monitors and identifies new recovery concepts not yet implemented within the organization to reduce claims overpayments within the claims system(s). Makes decisions guided by data and facts that will have the largest impact in reducing overpayments. Role also considers impact of overpayments that may affect member liability or a member questioning services rendered versus billed that could impact member retention. 5. Uses dashboards, reports, and data to conduct in-depth analysis and to evaluate the root cause of overpayments. Uses data to introduce and implement appropriate solution Partners with internal departments such as Finance, Claims, IT and Payment Integrity to forecast CRU financial impact. 6. Comfortable presenting results, objectives, and key activities to senior level leaders. Ability to make proposals and recommendations based on data to leadership. 7. Pro-actively works with Network to resolve complex provider recovery issues or problems while appropriately identifying opportunities to prevent costly overpayment recoveries pre-adjudication. Manages resources to resolve conflicting objectives and priorities within own area and to ensure financial, service and operational commitments are met. 8. Ability to work in a complex matrixed environment and partner with varying diverse individuals within an organization to customize a message up and down the organizational hierarchy. MINIMUM QUALIFICATIONS Bachelor’s degree in health administration or another field of study with equivalent working knowledge in the field of healthcare. Certified professional coder (CPC or equivalent). Seven years medical billing and/or coding experience, plus three years’ experience with 1500 and UB claims auditing, analyzing and researching medical records; knowledge of Medicare/Medicaid reimbursement guidelines including MS-DRG and/or APR-DRG; prior clinical or coding supervisory or management experience in managed care environment. Excellent communication, presentation and written skills in preparing and organizing data results. Basic Microsoft Excel experience in organizing and reporting data using pivot tables and other functions. Basic Microsoft Power Point experience in developing Senior Leadership presentations PREFERRED QUALIFICATIONS Current unrestricted RN (registered nurse) licensure in Arizona or equivalent working knowledge in the field of nursing. Three years’ experience in acute patient care environment. Masters preferred. High volume production/analytical environment with financially based goals. Additional related education and/or experience preferred. **EEO Statement:** EEO/Female/Minority/Disability/Veterans (https://www.bannerhealth.com/careers/eeo) Our organization supports a drug-free work environment. **Privacy Policy:** Privacy Policy (https://www.bannerhealth.com/about/legal-notices/privacy) EOE/Female/Minority/Disability/Veterans Banner Health supports a drug-free work environment. Banner Health complies with applicable federal and state laws and does not discriminate based on race, color, national origin, religion, sex, sexual orientation, gender identity or expression, age, or disability