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Area Standard Position Description 881280
SUPERVISORY HEALTH SYSTEMS SPECIALIST
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
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
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
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
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
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
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
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
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.
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
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
- 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
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
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
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
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
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
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
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.