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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Business Office Enhancement
 
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Area Standard Position Description 881280

SUPERVISORY HEALTH SYSTEMS SPECIALIST
G S-671-12

I. INTRODUCTION:
This position is located in a Service Unit Business Office located in Navajo Area I H S. The Service Unit is an inpatient facility with General Medicine and a Surgical Hospital. Specialty Services include Outpatient, Emergency, Obstetrics/Gynecology (O B/G Y N), Pediatrics, Mental Health and Social Services, Optometry and Dental Services; and Community Health Nursing.

The purpose of the position is to manage, evaluate, analyze, and provide Business Office functions that include Alternate Resources Program (Medicaid, Medicare and other third party resources). To provide oversight of a comprehensive health resource program. Assure an efficient and timely system of billing and collection of health care resources, patient admission eligibility determination, resources patient management, and training.

II. MAJOR DUTIES:
Business Office: 30%

Supervises and coordinates the functions and staff of the Business Office that include Branches in the Collections; Cash Control; Billing; Patient Registration; Patient Admissions and Benefits. Responsibilities include. This includes providing technical assistance to management, medical providers, patients and other facility personnel regarding the work of the departments.

Ensures development, implementation, and updating of Service Unit policies and procedures regarding Alternate Resources, and the Patient Care Component. Responsible for creation, implementation and maintenance of Business Office policy and procedures, which comply with the practices of an office supporting a private sector acute care hospital with a large multi-disciplinary ambulatory, care system. Policy and procedures will cover no less than the registration/admission processes to include insurance verification and pre-certification, billing and collection processes, cash control procedures for the posting of payments and contractuals, and the submission of periodic reports and their deadlines as required by the Health Care Financing Administration and other agencies

Serves as second line supervisor over 20 or more support staff in the Business Office Programs through three subordinate supervisory positions. Has the responsibility for coordinating and distributing workloads. Reviews the workload and progress of the office. Displays initiative in promoting suggestions to improve the overall operations as well as stressing cost containment.

Directs the activities of the Business Office Program including long and short range planning, evaluation and analysis, and projection of future requirements.

Serves as the focal point for all evaluations of the Business Office by N A I H S and I H S Headquarters. Determines the impact of such evaluations on operating programs and directs corrective action compliance through evaluation analysis in a timely and efficient manner.

Develops and implements a comprehensive internal quality control system within the program. Determines the effectiveness of such controls and their impact on the program.

Establishes and maintains a working relationship with Medicare and Medicaid intermediaries, state and federal agencies, area employers and private insurance companies. Ensures that cases of liability are reported to the Regional Attorney’s office.

Responsible for coordination of Business Office functions with the S U Finance, Clinical Services, Health Records, and M I S. Coordinates Business Office functions with the N A I H S Third Party Coordinator and other Navajo Area Service Units. Maintains close relationship with the Finance Office and Medical Records Department in coordinating collections for the third party reimbursement program. Develops statistical reports and control methods in determining receivable and collections.

Is responsible for the completion and submission of budgetary documents and reports required as part of the Service Unit’s budgetary process.

Responsible creation and maintenance of superbills by working with Clinical Service Chiefs to ensure capture of correct charges for services rendered to patients. Also works with all ancillary departments as well as the Departments of Surgery, Anesthesia and nursing units to assure all reimbursable services and supplies are captured for services rendered.

Assures that medical and dental providers have timely access to information on provider networks so that referrals are consistent with payment resources.

Responsible for acquisition and maintenance of hardware and software, and the required equipment and supplies for an efficient business office operation.

Responsible for the orientation and education of other departments and services of the S U to ensure compliance with new and existing regulations of federal, state and third party payers.

Monitors productivity of all reporting areas to ensure it meets production standards. Assures staff is provided a work environment conducive to productivity and good health.

Responsible for operational directions, including coordination of workload, assuring an effective and timely internal reporting system.

Trains employees and holds periodic in-house training sessions. Interprets regulations, requirements and procedures. Provides explanation on the inter-relationships of the various functions of the Business Office operation, Medical Records Department and Contract Health Service.

Provides or makes available training and continuing education for staff as appropriate. This may require arranging for on-site sessions conducted by consultants or sending staff to external training. Patient Care Component (P C C): 20%

Establishes, implements and evaluates the I H S Patient Care Component Program for the Service Unit. Through subordinate supervisor, is responsible for the development and administration of the P C C Program.

Coordinates all activities related to the P C C Program. Ensures that coordination of efforts takes place among the respective branches within the facility in activities and projects related to managed care. Alternate Resources: 20%

Coordinates Business office policies and procedures patient registration and admissions eligibility, resource patient management systems, and alternate resources programs through subordinate supervisor.

Through subordinate supervisor, coordinates collections for the third party reimbursement program. Develops statistical reports and control methods for determining receivables and collections. Utilizes the patient data base information system which includes conducting patient interviews to update information on demographic and third party resource data, recording the information and submitting it to the Navajo Area third party reimbursement office.

Makes final determinations on direct care eligibility of all individuals seeking care who have not previously established eligibility and of those individuals who have been treated previously and eligibility is now in question. Determines whether patient care falls within the scope of the I H S program. Requests documentary proof of eligibility when necessary. Exercised delegated authority to make a preliminary determination in cases of questionable eligibility and probable third party liability. The latter is to determine whether or not a tort liability upon some third party might be involved wherein the U. S. Government is requested to recover the cost of medical care furnished for disease or injury.

Establishes and maintains an effective communication and referral system with other hospitals and contract physicians concerning both elective and emergency patients.

III. FACTORS:

Factor 1 – Program Scope and Effect:
Scope: The scope of the work is to provide the full range of assessment of needs, planning for care, teaching and performance of research and evaluation for the Business Office. This position is the focal point and primary provider of advice and guidance of Business Office functions; is responsible for collection of all third party resources, and is responsible for the timeliness and accuracy of the third party billing activities. The incumbent is responsible for the overall direction and supervision of the registration/admitting functions, insurance verification/pre-certification, billing and collection of all third party and responsible party resources within the facility. The quality of each of these processes directly impact the speed at which reimbursement is received for services rendered to the beneficiary and non-beneficiary alike.

Effect: Failure to implement and monitor the provision of P. L. 99-272 and resolve billing problems or issues on a continuous basis adversely affect the I H S budgetary process. The completion of correspondence and forms as required by third party health insurance carriers in a timely and accurate manner will have a distinct bearing on dollars recovered and the ability to meet the goals and objectives of (a S. U.). The funds collected by the Service Unit and Area Office programs for projects and planning purposes, which aid the overall objective of elevating the health status of Indian beneficiaries. The successful efforts of the incumbent directly impact those funds collected.

Factor 2 – Organizational Setting:
The incumbent is under the direct supervision of the Administrative Officer or Health System Administrator who sets the overall objectives and resources available. Incumbent works with independence in the conduct of the program, requiring only occasional consultation with the supervisor for guidance in technical or policy areas. The Administrative Officer/H S A reports to the Chief Executive Officer (C E O), and the C E O reports to the Navajo Area Director.

Factor 3 – Supervisory and Managerial Authority Exercised:
Exercises delegated authority to:

  • Exercises delegated managerial authority to set a series of annual, multi-year, or similar types of long-range plans and schedules for the Business Office. Assures implementation (by lower and subordinate organizational units) of goals and objectives for the Business Office and other related functions it oversees. Determines goals and objectives that need additional emphasis; determines the best approach or solutions for resolving budget shortages; and plans for long range staffing needs, including such matters as whether to contract out work. These positions are closely involved with high-level program officials in the development of overall goals and objectives for assigned staff functions and programs.
  • Directs, coordinate, or oversees work of subordinate supervisors.
  • Exercises significant responsibilities in dealing with officials of other units or organizations, or in advising management officials of higher rank./li>
  • Assuring reasonable equity of performance standards and rating techniques developed by subordinates of the adequacy of billing and other related completed work. Ensures position descriptions are updated as necessary.
  • Directs the Business Office with significant resources (for example, one at multimillion-dollar level of annual resources).
  • Make decisions on work problems presented by subordinate supervisors.
  • Evaluates subordinate supervisors and serves as the reviewing official on evaluations of nonsupervisory employees rated by subordinate supervisors.
  • Makes or approves selections for subordinate nonsupervisory positions.
  • Recommends selections for subordinate supervisory positions for coordinating the work of others and similar positions.
  • Hears and resolves group grievances or serious employee complaints.
  • Reviews and approves serious disciplinary actions (for example, suspensions) involving nonsupervisory subordinates.
  • Makes decisions on nonroutine, costly, or controversial training needs and training requests related to employee with the department./li>
  • Approves expenses comparable to within-grade-increases, extensive overtime, and employee travel.
  • recommends awards for nonsupervisory personnel and changes in position classification, subject to approval by higher level officials and/or supervisors.
  • Explores and implements processes to eliminate or reduce significant bottlenecks and barriers to production; promotes team building and strives to improve business practices.
  • Analyze benefits and costs of accomplishing work in-house verses contracting; recommend whether to contract
  • Provide technical requirements and descriptions of work to be accomplished
  • Plan and establish the work schedules, deadlines, and standards for acceptable work; coordinate and integrate contractor work schedules and processes with work of subordinates or other
  • Track progress and quality of performance; arrange for subordinates to conduct any required duties
  • Plan work to be accomplished by subordinates, set and adjust short-term priorities, and prepare schedules for completion of work
  • Assign work to subordinates based on priorities, selective consideration of the difficulty and requirements of assignments, and the capabilities of employees
  • Evaluate work performance of subordinates
  • Give advice, counsel, or instruction to employees on both work and administrative matters
  • Interview candidates for positions in the unit; recommend appointment, promotion, or reassignment to such positions
  • Hear and resolve complaints from employees, referring group grievances and more serious unresolved complaints to a higher level supervisor or manager
  • Effect minor disciplinary measures, such as warnings and reprimands, recommending other action in more serious cases
  • Identify developmental and training needs of employees, providing or arranging for needed development and training;

Factor 4 – Organizational Setting:
Frequent contacts are with all levels of management within the Service Unit, Navajo Area, and I H S Headquarters personnel. Contacts are also with accrediting agencies, State and Federal agencies and third party carriers, Medicare and Medicaid fiscal intermediaries. Contacts may be informal occurring in conference or meetings, or telephonic conference calls sometimes requiring non-routine or special preparation. . Contacts may also include the general public and the patient population of the facility.

Purpose of personal contacts is to plan and coordinate the work of all functions the incumbent is responsible for. Additional purposes for contracts is to exchange information for clinical or financial purposes in an effort to obtain reimbursement for services rendered to beneficiaries and non-beneficiaries alike. Contacts are to resolve non-payment or partial payment of insurance claims, and to obtain pre-authorization/certification for admission reviews/extended care to assure maximum reimbursement for third party billing to the Service Unit. Responds to telephonic and written inquires from attorneys, insurance companies representatives, and patients/patients representatives, provides technical assistance and implements Business Office activities.

Factor 5 – Difficulty of Typical Work Directed:
Supervises subordinate supervisors who engage in performing a variety of professional, technical, administrative, and supportive activities. Provides direct technical supervision over the business office functions. Conducts meetings and conferences with subordinates supervisors and staff to explain work requirements, methods and procedures as needed, gives special instructions for difficult or complex activities, and answers technical questions about work assignments. The purpose of this position is the overall responsibility for the accounts receivable management function. This responsibility includes the overall supervision of all activities related to patient admission/registration, billing and collection, and posting of payments against the accounts receivable of the facility and it’s outpatient satellite clinics. The incumbent is responsible to establish guidelines, enforce standards and utilize judgement in the resolution of problems.

Formulates and issues written instructions and procedures for non-routine or complex assignments, new or changed programs, functions, procedures, personnel assignments and other operational matters proposed by subordinate supervisors. Makes decisions on problems not covered by precedents, protocols, or established policy. Reviews and analyzes records, reports and other evidence of work activities to evaluate performance. Continually studies processes to seek improvement in the quality and quantity of services and takes or recommends necessary action.

Factor 6 – Other Conditions:
The incumbent analyzes and evaluates the interrelated issues involved in the Business Office program. Develops detailed long-range plans for implementation of programs and develops criteria for evaluating their effectiveness. Work is difficult to analyze because of conflicting program goals, due to changes in legislative and regulatory guidelines. Work is further complicated by the need to deal with subjective concepts, such as value judgements, predictive measurements, and findings and consultations that are difficult to verify.

Incumbent has knowledge and understanding of established and standardized business office procedures and hospital policies sufficient to handle duties such as listed in section II of this document.

The work directed is judgmental and requires subordinates supervises to answer an extremely wide range of questions and inquires from the public, outside Federal, State, Tribal and local community leaders regarding any of the Business Office activities programs. In addition to providing the correct answers, the incumbent must also consider possible entitlement to the Business Office programs and the most advantageous way of processing the action or making further research for entitlement to all reimbursement activities. Information and circumstances vary based upon the multiple programs with complex entitlement provisions and the varying degree of comprehension of the Business Office programs by the public. The cultural diversity of the callers and the wide geographical area of coverage possible under the Business Office programs complicates the judgmental aspects of the job. Business Office guidelines are often incomplete in that they cannot cover every conceivable situation and the basic Business Office operating guides limit the amount of information available to the employee.

The work consists of analysis, evaluation of interrelated issues of substantive facility business program. Work requires developing detailed plans for long range implementation of programs and development criteria for evaluating their effectiveness. Work is difficult to analyze because of conflicting programs goals due to changes in legislation and regulatory guidelines. The position is highly complex due to the fact that the performance require skill sin multi-disciplinary matters ranging from health care financing to clinical subjects. The incumbent is highly visible both to other agency staff as well as other governmental and private officials.

Supervisory work of the incumbent is not complicated by any special situation and/or conditions, that is, variety of work, shift operations, physical dispersion, changing technology, etceteraetera.

The Service Unit may include a health center or satellite clinic. The hospital is an inpatient facility with 30 or more beds in a general medicine and surgical facilities with extensive outpatient services.

Knowledge of, and the ability to apply the Alternate Resources regulations; P. L. 94-437, Title I V of Indian Health Care Improvement Act, Indian Health Service Policy and Regulations on Alternate Resources, C F R 42-36.21 (A) and 23 (F), and P. L. 99-272, Federal Medical Care Cost Recovery Act, the Drug Abuse Office and Treatment Act of 1972, and hospital policies and procedures governing the recovery cost of medical care provided to certain individuals.

A working knowledge of International Classification of Diseases (I C D-9) and Current Procedural Terminology (C P T-4) coding. Knowledge of reimbursable insurance procedures and requirements including ability to interpret provisions of individual health and group plans.

Thorough knowledge of Medicare, Medicaid and third party payer regulations and how to work within their guidelines. Attendance at special workshops and training sessions in Medicare, Medicaid and other third party payers assists in staying current on changing regulations.

Knowledge of the Privacy Act of 1974 which mandates that the incumbent shall maintain complete confidentiality of all administrative, medical and personnel records, and all other pertinent information that comes to the attention or knowledge of the incumbent. The Privacy Act carries both civil and criminal penalties for unlawful disclosures of records. Violation of such confidentiality shall be cause for adverse action.

Knowledge of I H S organizational structure and operating policies. Understanding of the overall purpose and direction and assures maximum program effectiveness to meet the needs of I H S beneficiaries.

Principles and methods of sound management practices including appropriate channels of communication, prioritization and participative management. Excellent communication skills are required for training of staff on changes through continuing education.

Knowledge of the Resource Patient Management System (R P M S) and the accounts receivable management program. Keeps abreast of current changes in government regulations, collection laws, F T C rulings, third party payer procedures and internal procedures.

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

The work is primarily sedentary with the following physical requirements; Ability to lift up to 25 pounds, walk/stand for short periods of time as interaction between all disciplines with in the facility is required, ability to stoop and pick up objects from the floor without restrictions, and have full use of hands and arms, that is., to operate office equipment such as computer, calculator, printer, fax, etceteraetera.

All functions related to this position are normally performed within the hospital, clinic or office setting. Incidental use of a government vehicle may occur requiring a valid state driver’s license.

The Privacy Act of 1974 mandates that the incumbent shall 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 both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action.

IV. OTHER SIGNIFICANT FACTS:
Incidental use of government owned vehicle may be required, therefore incumbent must possess and maintain a state valid driver’s license.

E E O Statement: Within the jurisdiction of the immediate organization unit supervised, the incumbent is responsible for the application and implementation of E E O Program guidelines and the achievement of tangible E E O progress and results relative to minorities and women. Sets the tone through, and carries out the leadership role b initiating affirmative E E O action in selection details, reassignments, training, awards, career ladders and/or lattices, hiring, redesigning jobs, developing model in E E O matters for the benefit of subordinate supervisor and employees. Seeks out and utilizes all available resources in carrying out E E O responsibilities, i.e., the appropriate personnel generalists, E E O deputies and/or counselors, applicable training resources, etcetera. Reports will be submitted in regard to E E O maters as required.