> Business Office Enhancement - Management Tools Position
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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Management Tools

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LEAD MEDICAL CLERK (Office Automation)
G S-679-06

I. INTRODUCTION:
The position is located in the Business Office Services, Patient Registration Section at the Crownpoint Healthcare Facility. The incumbent serves a Lead Medical Clerk and works in various clinical settings (that is, Ambulatory Care, Emergency Unit, Inpatient Unit A / P / O B , satellite clinic Pueblo Pintado and Thoreau Clinic, Optometry, Dental, New Horizon, speciality clinic and Triage) on a rotation basis and provides assistance in determining eligibility for direct care services, obtaining registration (demographic and third party) information. Eligibility status is coordinated with the Utilization Management Program.

II. MAJOR DUTIES AND RESPONSIBILITIES:
Lead Responsibilities: (40%)
Assigns work to employees and explains work requirements, methods and procedures as needed. Insures timely performance of a satisfactory quality and quality of work. Reviews work product of employees and accepts, amends or rejects work.

Distributes and balances the workload among employees in accordance with established work flow. Assures timely accomplishment of the assigned workload.

Keeps in touch with the status and progress of work, and makes day-to-day adjustments in accordance with established priorities, obtaining assistance from the supervisor on problems that may arise, such as backlogs which cannot be handled promptly.

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

Instructs employees in specific tasks and job techniques and make available written instructions, reference materials and supplies.

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

Keeps employees informed of procedures, policies, directives, etcetera, and informs employees of available services, latest program developments and/or changes and employee activities.

Checks on work in progress or spot checks work not requiring review and reviews completed work to see that supervisor’s instruction on work sequence, procedures, methods and deadlines have been met.

Amends or rejects work not meeting established standards, refers to supervisor questions or matters not covered by standards and problems in meeting performance standards.

Approves leave for a few hours or for emergencies.

Reports to supervisor on performance, progress and training needs of employees, and on disciplinary problems. Provides information to supervisor regarding performance of staff as it may influence promotions, reassignments, awards, disciplinary actions, and other personnel needs.

Technical Duties: (60%)
Interviews patients to obtain pertinent patient registration information, that is, demographic and alternate resource information and pre-certification or prior authorizations for care to enable the Business Office to bill for health care services provided from all alternate resources, including non-beneficiaries.

Assist patients in completing new or updated forms for the Patient Registration System (R P M S). This includes inpatients, outpatients, emergencies and after-hour patients, specialty clinics, dental and mental health patients.

Determines the eligibility of patients seeking health care, who have not been treated at the facility, by obtaining the certificate of Indian Blood or other documentary proof of tribal membership, according to I H S guidelines.

Identifies those patients whose health benefits are subject to prior approval to determine the extent of health care for both inpatient and outpatient. Obtains and verifies the health records and the R P M S system for Medicare, Medicaid and private/commercial insurance eligibility information for all patients seen prior to all clinic visits.

Obtains all necessary signatures for file on required form(s) for alternate resources and contract health services prior to patients being seen in the clinic for billing purposes and/or contract health services eligibility.

In the event of claim information discrepancy; determines source of discrepancy and implements corrective action as appropriate to ensure that the claims can be processed for payment.

Collects third party, private insurance cards, Medicaid cards or other health care cards, photocopies and explains the program to the beneficiaries, that is, Medicare, Medicaid, A H C C S, private insurance and Managed Care organizations as to billing for their health care services they received at the Indian Health Service ( I H S ) facility.

Initiates pre-screening for all patients with no alternate resources for potential eligibility under the Medicaid, Medicare, A H C C S/County/State, A H C C S long Term Care, etcetera. Makes arrangements for patient and family to complete the required application process for these resources for which they may be eligible. Serves as an advocate on behalf of the patient and family to accurately identify and verify eligibility with these various resources. Also serves as an advocate on behalf of the patient and family during an appeal process if they are denied these resources. Assists in interpreting services to individual/family conference and to provide education information on any alternate resources, policy and procedures on behalf of the Service Unit.

Interviews patients to obtain information to initiate a new health record and communicates to Medical Records to reactivate a retired/stored record. Enters all information into the R P M S Patient Registration System and prints appropriate forms.

Performs other related duties as assigned.

III. FACTORS:
Factor 1 - Knowledge Required by the Position:
Working knowledge of eligibility requirements of the Indian Health Services program. Ability to apply a continuing awareness of constant revisions to avoid negative ramifications of allowing a non-eligible individual seeking medical care to enter the system, only to have to deny services after treatment has begun, except in case of emergencies. Knowledge of whether documented proof offered meets I H S requirements.

Knowledge of specialized medical terminology (for example, terms of anatomy) used in determining nature of patient request for treatment.

Ability to lead/instruct/train others, and to reorganize workflow, set priorities and determine best method to use to expedite the work of the department. Knowledge in coordinating, planning, and organizing assignments in order to make appropriate decisions on a day-to-day basis according to priorities, needs and goals of the department. Ability to train other employees.

Knowledge of basic supervisory techniques to manage activities in the Patient Registration section. Knowledge of interpersonal relations and skills to communicate in problem situations and report findings. Possess current knowledge and ability to answer questions of other employees on procedures, policies, directives, etcetera. and obtain needed information or decisions from supervisor on problems that arise.

Knowledge of various clinical systems, walk-ins and appointments to avoid unnecessary delays and/or confusion on the part of the patient. Knowledge of the various services offered by each clinic and forms used.

Knowledge of interviewing techniques, Managed Care services and Billing functions, policies and procedures to be able to refer inquires to appropriate personnel.

Knowledge of Privacy Act of 1974 and the use of confidential information and health records as an integral part of the interviewing office function and the privacy of individuals which must be protected to the fullest extent possible.

Knowledge of the R P M S Patient Registration System, its function, how to obtain appropriate information when needed and how to correct errors and update and/or change demographic information.

Knowledge of and ability to use typing keyboard. A qualified typist is required.

Able to interpret, in the Navajo language the non-English speaking patients are able to comprehend important information on their eligibility for direct care services, Contract Health Services and other Alternate Resources.

Factor 2 - Supervisory Controls:
Work is performed under the general supervision of the Supervisory Health System Specialist. The incumbent is fully responsible for administering the day-to-day activities of the unit with some margin for independence in carrying out responsibilities and following up on cases. The incumbent makes assignments by providing overall task objectives, goals and priorities. Assists the Medical Clerks with unusual situations which do not have clear precedents. The employee plans, coordinates, carries out assignments and handles problems and deviations in the work assignments using established policies and instructions. The supervisor is generally available for making decisions in unusual situations which do not have clear precedents or in cases when it is necessary for the incumbent to have supervisory support.

Work is primarily reviewed in terms of the overall efficiency of the services provided to patients, accuracy of the information obtained and through the post review of “error listing” and compliance with various guidelines. Reports from the R P M S Patient Registration system captures monthly activities for third party information and patient registration edits.

Factor 3 – Guidelines:
Written guidelines are found in the I H S manual, hospital circulars, technical manuals, policy and procedures, H C F A directives, Medicare/Medicaid and Contract Health Services regulations. However, these guides often do not have adequate information to deal with unusual problems. Judgment is used in locating and selecting the most appropriate guidelines, references and procedures. If necessary, incumbent makes minor deviations to adapt the guidelines to specific cases.

Factor 4 – Complexity:
Serving as the lead role, the incumbent performs a variety of functions. Distributes and balances the workload among the other employees. Ensures that work assignments of other employees in the unit are carried out. Instructs employees/answers questions in specific task and job techniques. Works in various clinics (that is, Ambulatory Care, Emergency Unit, Inpatient Unit (A / P / O B) satellite clinics (that is, Ambulatory Care, Emergency Unit, Inpatient Unit A / P / O B, satellite clinic Pueblo Pintado and Thoreau Clinic, Optometry, Dental, New Horizon, specialty clinic and Triage). Registers patients, updates demographic and third party information. Incumbent must be able to effectively communicate to the patient what specific information is needed, the reason for requesting such information, and be able to ascertain that it is accurate as possible. Consequence of obtaining inaccurate information may delay necessary medical treatment causing unnecessary frustration and problems. The work to be performed and documents/forms utilized vary with each department. Decisions regarding what needs to be done involves various choices that requires the employee to recognize the existence of the difference among the duties to be assigned, plus the process involved to complete the registration process.

Factor 5 - Scope and Effect:
The purpose of the work is to ensure the duties of the unit are identified, distributed, and performed to accomplish the workload in a timely manner. The work facilitates provision of complete and accurate Patient Registration demographic and third party data for the hospital and/or clinic. Duties such as the processing of authorized documents, courteous patient contact and good public relations affect the ability of the facility to provide quality patient care and program fund control.

Factor 6 - Personnel Contacts:
Personal contacts include coworkers, inpatients, outpatients, families, friends of patients, hospital personnel, physicians, employees from contract health, contracted billing, health records, clinical services, and administration. Other contacts include insurers (Medicare, Medicaid, A H C C S, private insurance companies, Managed Care organizations, etcetera) at the State, County and Tribal level. Contacts are also with utilization review coordinators and insurance verifiers.

Factor 7 - Purpose of Contacts:
Contacts are for providing assignments to staff employees. Contacts with patients are for obtaining insurance information, furnishing information of requested changes by patients, exchanging nd providing factual medical information to determine eligibility for services, length of stay authorized, and to provide liaison services to providers and recipients.

Factor 8 - Physical Demand:
Work is mostly sedentary, with some walking, standing and bending while interviewing patients and preparing the appropriate paperwork for treatment of a patient or initiating a chart.

Factor 9 - Work Environment:
Work is normally performed in an office setting, which is adequately lighted, heated and ventilated.

IV. OTHER SIGNIFICANT FACTORS:
Incumbent is required to work in various clinics ( that is, Ambulatory Care, Emergency Unit, Inpatient Unit A/P/O B, satellite clinic Pueblo Pintado and Thoreau Clinic, Optometry, Dental, New Horizon, specialty clinic and Triage) on a rotational shift on a (24) hour, (7) days a week, weekend shifts, Sunday shift and holidays.