Medical Billing & Claims Manager (DHPI98)

POSITION SUMMARY

The purpose of the position is to manage and lead the medical, pharmacy and dental billing of third-party payers applicable to outpatient, inpatient, ancillary, ambulatory surgery and professional services. Incumbent is responsible for management, providing technical direction and submission of properly executed claims in a timely manner to third party payers, responsible parties, and resubmission of corrected claims. Maximize reimbursement and minimize denied payments. Understand and monitor Patient Financial Key Performance Indicators while achieving the Clean Claim Goal established for TCRHCC. Responsibilities will also include delegation and assistance to the Director of Revenue Cycle.

NECESSARY QUALIFICATIONS

Education:

Associate degree in Business Administration or related business field (Finance, Accounting, Administration, etc.)

Experience:

• Minimum three-years of successful supervisory or management
• Minimum five-year experience as a medical billing technician in a tribal or non-profit healthcare patient accounting
• Demonstrated knowledge of ICD-10, and CPT/HCPCS coding/billing procedures, Uniform Hospital Discharge Data definitions regarding diagnostic and procedural sequencing in order to interpret and resolve problems based on information derived from system monitoring reports and the UB-04, HCFA-1500, and ADA billing forms submitted to the third-party
• Computer skills: ability to access and use multiple data

License/Certification:

• Obtain a Certification as a Revenue Cycle Representative through the Healthcare Financial Management Association (HFMA) one year from date of hire. Failure to obtain certification will result in termination of employment at TCRHCC.

Other Skills and Abilities:

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:

• Positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable; reports to work as scheduled without excessive absences and no reported attendance issues
• Ability to plan and lead effective team meetings and training
• Possess expertise in professional communication, interpersonal, organizational leadership and team building skills
• Possess excellent customer services skills for internal and external customers
• Ability to work under pressure and making quality and effective decisions
• Ability to positively motivate individuals and teams to meet or exceed department expectations/goals.
• Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by

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.

Physical:

The work is primarily sedentary, must have ability to sit for a prolonged period of time, and occasionally stand, walk, drive, bend, climb, kneel, crouch, twist, maintain balance, and reach. Must have ability to lift, push and pull over 100lbs occasionally. Sensory Requirements for position include prolonged telephone use, frequent far, near and color vision, depth perception, seeing fine details, hearing normal speech, and hearing overhead pages. Must have ability of both hand manipulation in prolonged use of keyboards, and frequent simple/firm grasping and fine manipulation.

Mental:

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. Must have ability of prolonged concentration and to work alone, frequent ability to cope with high levels of stress, make decisions under high pressure, handle multiple priorities in stressful situation, demonstrate high degree of patience, adapt to shift work, work in areas that are close and crowded, and occasionally cope with anger/fear/hostility of others in a calm way, manage altercations, and handle a high degree of flexibility including frequently accepting a flexible schedule to meet unit needs.

Environmental:

May occasionally be exposed to infectious disease, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.

ESSENTIAL FUNCTIONS:

1. Manages and leads the billing functions and staff in the medical (Institutional & Professional), Pharmacy and Dental, billing and
2. Thorough knowledge of third-party payer rules and regulations (i.e. Medicare, Medicaid, Managed Care, Commercial Insurance, Workers’ Compensation, Motor Vehicle Insurance)
3. Experienced with charge master, EDI claims, medical billing, E.H.R., CCI Edits and Claims Scrubbing, and Insurance Verification of Benefits systems.
4. Develops, implements and maintains billing policies and
5. Establishes and maintains a working relationship with Medicare and Medicaid intermediaries, state and federal agencies, area employers and private insurance
6. Proficient with MS Excel and Word software
7. Develops statistical reports and control methods, which identify insurer billing requirements, and productivity standards and results. Identifies limitations and provides information for staff
8. Provides technical assistance to management, medical providers, patients and other facility personnel by obtaining information relative to medical billing requirements, covered services, audit reports, or billing statistics,
9. Coordinates and oversees work of staff; has the responsibility of distributing workloads as
10. Responsible for maintaining time and attendance in timekeeping system of
11. Monitors productivity of staff to ensure it meets production Assures staff is provided a work environment conducive to productivity and good health.
12. Trains employees and holds periodic (in-house) training sessions. Assists in interpreting regulations, requirements and procedures; provides technical assistance to resolve patient accounting system
13. Reviews staff work for conformance to policies, procedures, and practices relating to Alternate Resources regulations, review of appropriate E&M, correct CPT/HCPCS codes, American Medical Association (AMA) requirements, American Dental Association (CDT-2), and the Health Care Finance Administration (HCFA)
14. Prepares and conducts employee job performance evaluations and forwards to Director of Revenue Cycle for
15. Responsible for the orientation and education of staff to ensure compliance with new and existing regulations of third party payers (i.e. covered services, limitations, ).
16. Assists with testing of new software, implementation of new payer requirements and guidelines, CMS regulatory guidelines, new process flows,
17. Evaluates and addresses issues and concerns relative to daily operations of assigned areas, also provides recommendation/suggestion to improve the overall operations (i.e. cost containment via personnel management) to the Director of Revenue Cycle
18. Responsible to initiate, carry out, and enforce disciplinary action policy and procedure with staff when
19. Verifies accuracy of services and billed amounts, and that services are allowed by appropriate regulations, directives and payer guidelines.
20. Identifies errors, omissions, duplications in documents and contacts the appropriate individuals to resolve
21. Responsible for providing monthly reports, organizing schedules (i.e. regular, overtime, ).
22. Attends and participates in management meetings as
23. Accepts delegation in the absence of immediate
24. Ensure proper PPE is always worn while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH- approved N95 filtering facepiece respirator or higher, if available), and eye or face
25. Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE (see CDC website for most current updates)
26. Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer
27. Performs other duties and special projects as assigned or required.