U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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G S-525-06

This position is located in the Business Office Services Branch of the Chinle Comprehensive Health Care Facility. The position performs accounts receivable support functions for the patient account system, through the posting of payments and adjustments to accounts receivable in the Patient Accounts Section.

10% Maintains accounts by reviewing documents to verify accounting data as necessary, entering data into the system. They reconcile accounts comparing account balances with related data to assure agreement; reviewing records and source documents to identify the sources of discrepancies; and determining the entries required to bring the account to balance. Prepare reports reflecting the examinations made, discrepancies noted, and the corrective entries required adjusting accounts.

10% Examine accounts or resolve difficult reconciliation requiring an analysis of adjustments and corrective entries in the patient account system. Trace transactions entered and prepare and/or provide supporting documents reflecting the source of discrepancies, corrective action required to bring accounts into agreement, prove the accuracy of adjusted accounts, and recommend actions to prevent recurrence of similar discrepancies.

5% Performs work consisting of examination for accuracy of claims and other request for payment for (1) services provided by the Government; (2) reimbursement of expenditures made by beneficiaries and non-beneficiaries for such purposes as medical care and treatment.

5% Maintains the automated accounts receivable ledger associated with third party payer claims. Responsible for associated records and documentation. Reviews and reconciles all third party payer documents for correct data, on all third party vouchers for accurate claim numbers.

5% Prepares all pertinent documents for refunds to payers, this process involves direct communication with payers and Navajo Area Finance. All refunds under $500 dollars are processed here at the Service Unit Level. Public Vouchers are initiated and processed, the Administrative Resource Management System is utilized in making sure payment has been processed.

5% Prepares monthly, quarterly and annual reconciliation and recapitulation of third party billing to assure that collections, billed data, and the computerized and manual reports are in balance.

5% Prepares monthly reports: Upload Third Party Bills by Approval Data(s), this process ensures that duplicate bills are not crossed over to the Accounts Receivable program. The Bill File Error Scan, this process is used to compare the billing file against the Accounts Receivable file making sure that there are no errors setting in the edit mode of Third Party Billing. Third Party Reload by Date, this process is used to correct any discrepancies noted as a result of the Bilstal File Error Scan. These reports are vital to the Accounts Receivable process.

10% Reviews and examines various bill types, of patient care to third party payers and performs third party collection posting to the automated account receivable program. Receives and reviews all Explanation of Benefit and remittance from third party payer. Identifies and records proper claims numbers on each remittance and post to the appropriate account.

10% Responsible for the posting of all contractual/adjustments related to and in conjunction with posting of payments in accordance with hospital policy and procedures. Monitor accounts balances, review posting to ensure accuracy and recommend appropriate corrective action.

10% Audits all documents received for completeness and accuracy; analyze and select guide to determine whether payments are full or partial in accordance with hospital policy and procedures; whether they are timely; and whether remittance are advances, installments, or supplements.

5% Responsible for accurate processing of secondary and tertiary billing after posting payment of initial claims.

5% Maintains current documentation and guidelines pertaining to reimbursement activities in appropriate files, binders, etc., and ensures preparation and distribution of copies to all appropriate disciplines.

5% Maintains Electronic Data Interchange (E D I ) applications for automated posting into R P M S Accounts Receivable. Initiates file transfer of A N S I x 12 835 file (electronic Remittance Advice & Explanation of Benefits) from P N C Bank to computer work station in the Business Office. Initiates download of electronic files to R P M S-Accounts Receivable module. Monitors, identifies and reports any application problems with non-H I S (Envoy) programmers. Provides hardcopy 835 reports to Finance and to Tsaile Health Center.

3% Incumbent safeguards the contents of the alternate resources program health insurance claims as privileged communication which disclosure of information only within the limits of I H S policy.

2% Completes special projects within required time frame to ensure compatibility of project specifications.

5% Verify the accuracy of payment history for the period involved, determines the extent of underpayment or overpayment, if any. Responsible for assisting in the timely resolution of unidentified cash received by the hospital according to hospital policy and procedures.

Factor 1 – Knowledge Required by the Position
Knowledge of extensive and diverse accounting, other financial regulations, operations, and procedure governing a wide variety of transactions involving nonstandard patient accounts, complaints or discrepancies.

Knowledge of a variety of accounting transactions and documents, accounting symbolic codes, account structures, and procedures for setting up and crediting accounts receivable.

General knowledge of third party payer reimbursement logic and of the total accounts receivable management program. Excellent communication skills are required for interaction with the third party payer community.

Knowledge of wide variety of interrelated procedures and processes required to assemble, review, and maintain complex accounts related to patient account transaction (for example, adjusting accounts or processing refunds involving numerous supporting schedules).

Knowledge of established procedures, reimbursement format, etc., associated with the various reimbursing third party payers.

Knowledge of resolving problems in balancing patient accounts, adjusting discrepancies. Develops control records, verifying the accuracy of budgetary data adjusting dollar amounts on accounts by line item and preparing reports reflecting the discrepancies.

Knowledge of automated patient accounting system and third party billing system to reconcile errors that require an understanding of nonstandard procedures related to patient accounts. Provides assistance in the development of automated patient account procedures for clerical operations of the Business Office.

Knowledge of automated systems, ability to type, and operate a calculator.

Knowledge of total program operations, the priorities and goals of the Alternate Resources Program. Keeps abreast of current changes in policy regulations on eligibility. Participates in planning, implementation, and improvements of the accounts receivable program.

Working knowledge of I C D-9-CM and C P T/H C P C S coding terms in order to interpret and resolve problems based on information derived from system monitoring reports and the U B-92 and H C F A-1500 billing forms submitted to the third party payer.

Knowledge of and ability to apply the Alternate Resources regulations; P. L. 94-437, Title IV of Indian Health Care Improvement Act, Indian Health Service Policy and Regulation on Alternate Resources, C F R 42-36.21 (A) and 23 (F), and P. L. 99-272, Federal Medical Care Cost Recovery Act.

Factor 2 – Supervisory Controls
The incumbent works under the supervision of the Business Office Manager who establishes general guidance and advice, and suggests techniques for handling unusual or nonrecurring situations, which have no clear precedents. Incumbent works independently processing the most difficult procedural and technical tasks or actions, and handles problems and deviations in accordance with instructions and policies.

Independently determines the types and sources of information needed to complete the transaction; the nature and extend of deviation from established requirements; and whether standard techniques, methods or procedure are appropriate for assignments.

Factor 3 – Guidelines
Guidelines include established agency policies and procedures, federal codes and manuals, specific related regulations and processing manuals. The incumbent uses judgement to locate and select the most appropriate guide, and is expected to use judgement and initiative in handling aspects of the work not completely covered. Makes minor deviations in guidelines to adapt to specific cases.

The incumbent makes decisions, devises solutions, and takes action based on program knowledge related to patient accounts. Interprets considerable data to identify problems and determine reason for non-payment on patient accounts. Resolves issues, recommends and implements solutions and revises or develops alternative methods for resolution.

Factor 4 – Complexity
Patient account support duties involve different and unrelated processes and methods. Position works with various programs which cover different states and each health insurance program having different benefits, deductible, and eligibility requirements. Incumbent makes recommendation for claims, verifying factual data or making other determinations based on a case by case review of pertinent regulations, documents or issues involved in each assignment or situation. Determines how each step of the accounts receivable process should be performed in accordance with available guidelines and instructions, and proceeds accordingly. At each stage of the process, decides whether proper procedures and being followed.

Incumbent downloads electronic files from (3) major Third Party Payers. The work involves working with programmers from private companies, contracted for these services. Monitors all electronic files received and identifies and problems. Problems are immediately reported to the programmers. The incumbent processes secondary and tertiary billing after posting payment of initial claim. The work involves knowledge of third party billing requirements by each payer, and ability to make accurate determination if the claim is secondary or tertiary, by reviewing accounts receivable posting.

Factor 5 – Scope and Effect
The position applies specific rules, regulations or procedures to perform a full range of related accounting and technical tasks that are identified in the Business Office third party collection process. The incumbent assists in the posting of payments and contractual/adjustments due for services rendered to Indian Beneficiaries and Non-Beneficiaries alike. The work affects the organization’s records, program operations and service to clients. The work also ensures the integrity of the overall accounts receivable program, its basic design and the adequacy of the overall operation of the Business Office and various operating programs.

Factor 6 – Personal Contacts
Regular and recurring contact are with employees in the hospital, with local and state agencies, third party payers, Medicare and Medicaid fiscal intermediaries.

Factor 7 – Purpose of Contacts
The purpose of contact are to plan and coordinate the cash posting functions of the Business Office. This includes resolution of problems pertaining to posting of remittance and contractual/adjustments to patient receivables, and to resolve any unidentified remittances received for health care services rendered.

Factor 8 – Physical Demands
> The work is primarily sedentary with some physical requirements. Lifts or carries files, supplies or equipment; walks and stands to interact between all disciplines within the facility; stoops and picks up objects from the floor and have full use of hand and arms to operate office equipment such as computer, calculator, printer and fax.

Factor 9 – Work Environment

Work is performed in the Business Office setting.

Other Significant Facts
The Privacy Act of 1974 mandates that the incumbent maintain complete confidentiality of all administrative, medical and personnel records and all other pertinent information that comes to his/her attention or knowledge. The Privacy Act carries civil and criminal penalties for unlawful disclosure of records, violations shall be cause for adverse action