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G S-503-08

This position is located in the Business Office Services Branch of the Gallup Indian Medical Center. G I M C is a 99 bed general surgical referral, teaching hospital that provides surgical care, acute and both inpatient and outpatient services to approximately 6000 inpatients per year and 220,000 outpatient visits per year. The position is responsible for the full range of technical services in coding, abstracting and billing functions. This includes the submission of properly executed claims on a timely basis to third party payers and responsible parties, and rebilling or correcting billing of accounts previously submitted. The position also serves as work leader for six (6) Billing Technician’s accomplishing the work within the Billing Section.

Leader Responsibilities:

Leads six (6) Billing Technicians G S-503-07 engaged in coding, abstracting and billing activities in the Business Office. Assures that work assignments of the employees are carried out effectively and efficiently.

Monitors the status and progress of work, and makes day-to-day adjustments in accordance with established priorities. May request supervisory assistance when problem(s) arise, such as backlog, which cannot be handled promptly.

Estimates and reports on expected time of completion of work, and maintain records of work accomplishments and time expended, prepares production reports as requested.

Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies provided when appropriate. Ensure that required policies and procedures and regulations are available.

Provides on-the-job training to new employees in accordance with established procedures and practices.

Reviews and ensures that work completed is accurate and procedures methods and deadlines have been met.

Approves leave for a few hours or for emergencies.

Resolves simple informal complaints of employees and refers others to supervisor.

Reports to the supervisor on performance, progress and training needs of employees and/or disciplinary problems.

Provides information to supervisor regarding performance of staff as it may influence promotions, reassignments, awards, disciplinary actions, and other personnel needs.

Billing Responsibilities:
Receives and examines alternate resources claims to assure claims are complete with appropriate supporting documents which typically include utilization review certifications. Verifies accuracy of health claims number, that claimed amounts are authorized, and that items of services billed are allowed by appropriate regulations, decisions, directives and other controlling guides. Identifies errors, omissions, duplications in documents and contact the appropriate individuals to resolve problem.

Provides technical assistance with processing and maintaining C P T coding, abstraction of the complete chart (outpatient) and compliance enforcement of all regulatory requirements. Review, analyze C P T coding, abstract and compile data, maintain and identify potential risk areas in outpatient medical record. All information will be used for manual data analysis for the business office, compliance officer, medical records and administration.

Searches and abstracts all C P T coding, operative and therapeutic and all other pertinent data from the medical records in order to identify and document appropriate patient care and other information necessary for billing.

Conducts a thorough review of all abstraction and search of records, guidelines in order to select the most accurate and descriptive codes in accordance with C P T / H C P C S coding system. Code selection involves discriminating between several different codes, which can overlap in scope, encompass multiple diagnosis, treatments or operations; and include special codes to denote causes of accident/injury or adverse effects required for billing.

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. Updates medical record charge out guide on all records received and analyzed.

Abstracts all necessary information by auditing the appropriate E & M and assigning the correct C P T / H C P C S code, which most accurately describes each medically documented procedure according to established guidelines and practices for outpatient visits. Uses official coding conventions, techniques, rules established by the American Medical Association (A M A), American Dental Association (C D T-2) and the Health Care Finance Administration (H C F A) for assigning codes.

Consults with the attending physician, laboratory and all other necessary departments for compliance with all the regulations and guidelines, pertinent to False Claims Act and facilities Compliance program in preparation for itemize billing.

Responsible for maintenance and control of unbilled claims for an assigned section of patient receivables. Notifies supervisor of all claims deemed unbillable, along with reason(s) on a daily basis.

Reviews system generated reports daily to identify claims that are ready for billing. Prepare and submit claims to third party payers, intermediaries or responsible parties within 48 hours after all information for billing becomes available.

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.

Serves as contact person relative to any questions or problems with claims processing. Such contacts involves a variety of program and coding related matters, interpretation of regulatory material and determining the applicability of guidelines and instructions to problem or situations which in many instances, are not specifically covered. Makes recommendations for changes in methods and procedures, information dissemination and other processing matters to resolve recurring problems and expedite processing actions.

Documents all activity performed on patient accounts in the patient financial folder such as date billed and to whom.

Provides supervisor with an accurate accounting of all claims in the assigned section of patient receivables responsible for. Submits a daily billing Productivity Report reflecting the beginning inventory, claims billed and remaining balance at end of shift.

Responsible for self-education by reading all third party newsletters, periodicals and updates circulated by management. Attends all continuing education opportunities made available.

Responsible for automated transmission of all third party claims in a timely matter, as specified by policy and procedures.


Factor 1 – Knowledge Required by the Position
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.

Knowledge of the total Alternate Resources Program operations, priorities and goals.

Through knowledge of all third party claims submission process and ability to keep current on changes in policies, regulations of eligibility. Knowledge of established procedures, required forms, etcetera, associated with the various third party payers.

In-depth knowledge of I C D-9 and C P T 4/H C P C S coding procedures, Uniform Hospital Discharge Date definitions regarding diagnostic and procedural sequencing 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 how to establish and maintain relationships with the third party payer community necessary for resolution of outstanding claims.

Knowledge of the on-line input terminal equipment and automated electronic billing system(s).

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 ruling, third party procedures and internal procedures.

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

Ability to analyze complex medical and regulatory information to arrive at the most logical and advantageous method of billing.

Ability to lead/instruct/train employees, and to reorganize work flow, set priorities and determine the best method to use to expedite work of the section.

Ability to exercise considerable tact in maintaining effective work relationships with various employees, clients and patients. Position requires extreme accuracy and timeliness in all phases of work.

Excellent communication skills are required for training of staff on changes through continuing education, and communication with medical staff.

Knowledge and familiarity with rules and regulations pertaining to a compliance program and various aspects of compliance issues, specially coding and billing issues and its relations to I H S.

FACTOR 2 – Supervisory Controls
The incumbent works under the general supervision of the Supervisory Health System Specialist, who establishes general guidance and advice, and suggests techniques for handling unusual or nonrecurring situations, which have no clear precedents or situations that require extensive analysis and evaluation. Employee works on own initiative and independently resolves problems within the scope of policies and the compliance program. Work is reviewed for adherence to policies and regulations.

FACTOR 3 – Guidelines
Guidelines used are Encoder and R P M S users guide, the Privacy Act, medical dictionaries, I H S and service unit manuals, J C A H O, and Facility Compliance Program guidelines, written and oral policies procedures. Incumbent uses judgment to adapt and interpret guidelines for application to specific, complex cases or problems. Uses initiative and discretion in deciding on the right course of action to correct deficiencies and improve reliability of information in records.

FACTOR 4 – Complexity
The incumbent performs complex, varied non-standardized tasks requiring applications of laws, regulations, Compliance Program policies and procedures. The incumbent determines the most accurate and descriptive codes in accordance with C P T / H C P C S coding system and guidelines set forth by H C F A and other third party payers. 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.

FACTOR 5 – Scope and Effect
Reimbursement conclusions reached and the decision made effect the patient/physicians relationship, and the effectiveness of our coding/billing program. The successful efforts of the incumbent directly impact the funds collected resulting in the ability of G I M C to utilize alternate health resources effectively, optimizing reimbursements for health care rendered, which aid the overall objective of elevating the health status of Indian Beneficiaries.

FACTOR 6 – Personal Contacts
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 Compliance Officer, Utilization Review Coordinator and Insurance Institutions and Services.

FACTOR 7 – Purpose of Contacts
The purpose of the contacts is to plan and coordinate the work of the coding/billing abstracting and claims submission function of the Business Office. Including resolution of problems pertaining to coding/billing of inpatient/outpatient claims and to resolve issues pertaining to services rendered and any returned claims for Indian Beneficiaries and Non-Beneficiaries.

FACTOR 8 – Physical Demands
The work is primarily sedentary requiring some bending, walking, standing and carrying of patient records and light supplies. No unusual physical demands are required.

FACTOR 9 – Work Environment
All functions are normally performed in the Business Office setting.

Other Significant Facts:
Incumbent will be required to work day, evening and holiday shifts.

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.