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LEAD BILLING TECHNICIAN
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.
II. MAJOR DUTIES AND 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
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
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.
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
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
Knowledge of how to establish and maintain relationships with
the third party payer community necessary for resolution of outstanding
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
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
Excellent communication skills are required for training of staff
on changes through continuing education, and communication with
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
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.