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PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary:

Under general supervision, the incumbent is responsible for examining, verifying, and maintaining data involved in processing medical care claims for alternate resources reimbursement and performing other third-party billing-related duties. The primary function of this position is to bill/process all medical care claims timely to ensure reimbursement from third-party payers.

Scope of Work:

The work involves the review of medical claims to ensure accuracy and completeness and obtain missing information. The incumbent performs various accounting, budget, or financial management support-related duties or assignments related to medical billing.

Essential Duties and Responsibilities:

• Responsible for received claims up until Third-Party Payer has paid the claim.
• Receives and examines alternate resource claims to ensure they are complete with appropriate supporting documents.
• Verifies accuracy of health claim number that claimed amounts are authorized and that the items of services billed are allowed by appropriate regulations, decisions, directives, and other controlling guides.
• Identifies errors, omissions, and duplications in documents and contacts the individual to resolve the problem before the claim is approved and submitted for reimbursement.
• Abstracts all necessary information by auditing the appropriate E&M and assigning the correct CPT/HCPCS code, which most accurately describes each medically documented procedure.
• Uses official coding conventions, techniques, rules established by the American Medical Association (AMA), American Dental Association (ADA) (CDT-2), and the Health Care Finance Administration (HCFA) for assigning codes.
• Search and abstract all CPT coding, operative and therapeutic, and all other pertinent data from the medical records to identify and document appropriate patient care.
• Conducts a thorough review of all abstraction and search of records using guidelines to select the most accurate and descriptive codes per CPT/HCPCS coding system.
• Ensures billing outpatient claims are within six (6) business days from the date of services.
• Ensures billing inpatient claims are within ten (10) days.
• Batches bills and prepares all invoices and listing patient's names for submission to Blue Cross/Blue Shield Fiscal Intermediary, Medicare, Medicaid, Private Insurance, and any alternate resources.
• Maintains a transmittal log on claims transmitted electronically and ensures follow-up when files are sent electronically of all alternate resource bills.
• Serve as a contact person relative to any questions or problems with claims processing and coding problems.
• Makes recommendations for changes in methods and procedures, information dissemination, and other processing matters to resolve recurring problems and expedite processing actions.
• Determines that claims are correctly processed and that the total agrees with the pre-determined control totals.
• Review reports and listings to ensure that they are in balance, proper format, sequence, and valid data.
• Maintains a timely filing system that includes third-party documents, remittance advice, and transmittal from third-party payers, which advise changes in coverage or billing procedures.
• Provides technical assistance with processing and maintaining CPT coding, abstraction of the complete chart (outpatient), and compliance enforcement of all regulatory requirements.
• Identifies inconsistencies or discrepancies in medical documentation by notifying the appropriate providers and all other departments within the facility for complete charge capture and abstraction.
• Consult with the attending physician, laboratory personnel, and all other necessary departments for compliance with all regulations and guidelines pertinent to the False Claims Act and Facilities Compliance program in preparation for itemized billing.
• Adds and edits insurers to the insurer file, completes claim formats and works closely with Patient Registration to maintain the insurer file.
• Responsible for maintenance and control of unbilled claims for an assigned section of patient receivables.
• Reviews system-generated reports daily to identify claims that are ready for billing.
• Prepares and submits claims to third-party payers, intermediaries, or responsible parties within 48 hours after all information for billing becomes available.
• Correct errors for all rejected/suspended claims previously submitted to third-party payers and intermediaries, and patients according to hospital policy and procedures.
• Documents all activity performed and patient accounts in the patient financial folders, such as the date billed and with whom.
• Provide the supervisor with an accurate accounting of all claims in the assigned section of patient receivables.
• Submits a daily billing Productivity Report reflecting the beginning inventory, claims billed, and remaining balance at the end of shift.
• Manages Provider Files: (a) Keeps licenses up to date for Providers and (b) completes provider application for NPI, AHCCCS, and Medicare numbers.
• Manages all access to Insurance Online data: (a) manages username and password, and (b) provides training for online usage.
• Utilizes word processing and other automated equipment to perform various tasks, such as extracting and listing items from text, transmitting to other terminals, printing, formatting, filing in archives, recalling, etc.
• Performs other job-related duties as assigned and contributes to a team effort.

Knowledge, Skills, and Abilities:

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Knowledge of and skill in applying a broad body of accounting, budget, or other financial management regulations, practices, procedures, and policies related to the specific revenue cycle associated with medical billing.
• Knowledge of hospital admitting requirements and procedures, including documents required for admission, transfer, discharge, AMA, or death; and types of medical problems treated by each sub-division clinic (e.g., orthopedics, neurology, urology, surgery) to make appropriate and timely referrals.
• Knowledge of standard medical terms of the anatomy, common drugs, and correct spelling and appropriate medical abbreviations.
• Knowledge of the hospital/clinic organization and operations and familiarity with the work processes of organizations with which the agency must coordinate and abide by Federal Regulations and standards.
• Knowledge of legal regulations and requirements on confidentiality, specifically to the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Knowledge of various interrelated steps, conditions, and procedures or processes required to assemble, review, and maintain complex billing.
• Knowledge of a variety of billing, collections, accounting, and budget functional areas and their relationships to other functions to research or investigate problems or errors.
• Knowledge of automated billing, collection, eligibility, claims, accounting, and budget systems to reconcile errors that require an understanding of nonstandard procedures.
• Knowledge of billing, collections, follow-up, adjustment and accounting methods, procedures, and techniques to conduct responsible and challenging analysis and determinations.
• Knowledge of an extensive body of alternate reimbursement policies, regulations, instructions, and the interrelationship of the procedures and regulations on eligibility.
• Knowledge of the various titles of the Medicare and Medicaid federal regulations, other public laws, and regulations that apply to or affect the operation of billing of Third Party resource programs.
• Knowledge of technical interpretation of rules and regulations and applying to all Third-Party Payers for accurate reimbursement.
• Knowledge of the Resource Patient Management System (RPMS) and the Third Party Billing program.
• Knowledge of all third-party claims submission processes and ability to keep current on changes in policies, regulations of eligibility.
• Knowledge of the Utilization Review System, Program Operations, and specialized medical terminology related to direct patient care when applied to Inpatient Billing.
• Knowledge of the Freedom of Information Act (FOIA) and the Privacy Act of 1974, and other applicable privacy information protecting the use of confidential information and health records.
• Knowledge of and the ability to apply the Alternate Resource regulations; P.L. 94-437, Title IV of Indian Health Care Improvement Act, Indian Health Service Policy and Regulations on Alternate Resources, CFR 42-36-21 (A) and 23 (F), and P.L. 99-272, Federal Medical Care Cost Recovery Act.
• Knowledge of the total Alternate Resources Program operations, priorities, and goals.
• Knowledge and familiarity with rules and regulations of a compliance program and various aspects of compliance issues, specifically coding and billing related to the Hospital.
• Knowledge of ICD-10 and CPT 4/HCPCS coding procedures, Uniform Hospital Discharge Date regarding diagnostic and procedural sequencing which affects Diagnoses-Related Group (DRG) assignments.
• Knowledge of Common Procedure Terminology (CPT) coding utilizes the national fee scale for processing private insurance claims reimbursements.
• Knowledge of online input terminal equipment and automated electronic billing system(s).
• Excellent communication skills are required to train staff on changes through continuing education and communication with medical staff.
• Skill in typing and basic computer word-processing, calculator, spreadsheets, and database software programs.
• Skill in providing superior customer service to external and internal customers.
• Ability to interpret and resolve problems based on information derived from system monitoring reports and the UB-92 and HCFA-1500 billing forms submitted to the third-party payer.
• Ability to analyze complex medical and regulatory information to arrive at the most logical and advantageous billing method.
• Ability to exercise considerable tact in maintaining effective work relationships with various employees, clients, and patients.
• Ability to handle multiples tasks and meet deadlines.
• Ability to exercise independent judgment.
• Ability to carry out instructions furnished in verbal or written format.
• Ability to communicate efficiently and effectively verbally and in writing.
• Ability to establish and maintain positive and effective working relationships with other employees and the general public.
• Ability to maintain confidentiality.

Minimum Qualifications:

• High School Diploma or General Education Diploma.
• Two years of work experience in medical billing, third-party billing, accounting, budget, financial management support, or equivalent.

Licenses, Certifications, Special Requirements:

• Must type 40 WPM.
• Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39-month driving record.
• May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
• If required, must meet the Tohono O'odham Nation tribal employer's insurance requirements to receive a driver's permit to operate program vehicles.
• Based on the department's needs, incumbents may be required to demonstrate fluency in both the Tohono O'odham language and English as a condition of employment.