This position has responsibility for a full range of technical services of billing functions that includes the oversight of properly executed claims on a timely basis to third party payers and responsible parties, and rebilling or correcting previously submitted billing of accounts. The incumbent determines the most accurate and descriptive codes in accordance with CPT/HCPCS coding guidelines set forth by the Health Care Financing Administration (HCFA) and other third party payers. The incumbent has regular and recurring contact with employees, patients, families, Contract/ Third Party Payers, Clinical Services Professionals and Administrative staff and constant contact with the Compliance Office, Utilization Review, and Insurance Institutions.
1. Receives and examines alternate resources of claims to assure claims are complete with appropriate supporting documents which typically include utilization review certifications. Responsible for transmission of all third party claims in a timely matter as specified by policy and procedures.
2. Verifies accuracy of patient account number, claim amount is authorized, and appropriate regulations, decisions, directives and other controlling guides allow items of services billed. Identifies errors, omissions, duplications in documents and contact the appropriate individuals to resolve problem.
3. Searches and abstracts all CPT, ICD9, and HCPCS coding and all other pertinent data from the medical records in order to identify and document appropriate patient care and other information necessary for billing.
4. Identifies inconsistencies or discrepancies in medical documentation by notifying the appropriate providers and/or all other departments within the facility for complete charge capture and abstraction. All providers and identified risk departments will follow-up to assure completion in compliance with hospital’s policy and compliance program. Keeps this system updated at all times to ensure accurate reports.
5. Consults with the attending physician, laboratory, radiology and all other necessary departments for compliance with all the regulations and guidelines pertinent to False Claims Act and Compliance program in preparation for itemized billing.
6. 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.
7. Responsible for the error correction for all rejected/suspended claims previously submitted to third party payers and intermediaries and patients according to hospital policy and procedures.
8. Responsible for keeping up to date with assigned payer billing rules and guidelines.
9. Performs other duties and responsibilities as assigned.
1. Responsible for super-user duties; researching and troubleshooting issues, assist with new system and process implementation, assist with system upgrades and testing, and complete system training certifications.
2. Perform case work duties such as in-depth research and maintaining of files related to workman’s compensation and motor vehicle accidents from open to closed cases. Communicates closely with employee, employer, payer, attorneys, and all others involved in each case. Submits and releases liens with county courthouses. Performs the negotiation process with all third party payers, intermediaries, and patients.
3. Performs all duties of Technician Level.
4. Performs other duties and responsibilities as assigned.
The incumbent performs complex, varied non-standardized tasks requiring applications of laws, regulations, Compliance Program policies and procedures. Uses a complex body of specialized subject matter knowledge and good interviewing or investigating techniques to assure accurate information is abstracted in a courteous and efficient manner. The billing process consists of duties that involve different and unrelated processes and methods. The complexity of the work involves working with various programs, covering several states and third party payers who have different benefits and remittance formats.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
The work is primarily sedentary; ability to lift up to 25 pounds, walk/stand for short periods of time; ability to stoop and pick up objects from the floor without restrictions, and have full use of hands and arms, i.e., to operate office equipment such as computer, printer, fax, etc.
Exercises initiative and judgment in deviating from existing department or corporation practices to resolve billing issues/concerns. Work is reviewed for conformance to policies, procedures, and practices relating to billing practices.
The funds collected are used by the corporation for funding daily operations and expending capital projects, planning purposes, and core operations, which are essential to the overall objective of elevating the health status of Indian beneficiaries. The successful efforts of the incumbent directly impact the funds collected and the financial viability of the medical center.
TCRHCC is located within the Navajo Nation and, in accordance with Navajo Nation law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this Policy, applicants who are enrolled members of the Navajo Nation and who meet the necessary qualifications for this position will be given preference in hiring and employment for this position and applicants who are enrolled members of any other tribe who meet the necessary qualifications will be given secondary preference.
In performance of their respective tasks and duties, all employees at TCRHCC are expected to conform to the following:
- Adhere to all professional and ethical behavior standards of the healthcare industry.
- Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
- Possess cultural awareness and sensitivity.
All employees must uphold all principles of confidentiality and patient care to the fullest extent.
I have read the qualifications and requirements for the position of Medical Billing Technician I/II/III. To the best of my knowledge, I believe I can perform these duties.