PRC Accounts Specialist

Other Santo Domingo, New Mexico


Description

Purchased referred care (prc) Account Specialist

Description

Open: 08/13/2021
Closes: Open until Filled

Work Schedule: Monday through Friday, 8 a.m. to 5 p.m.

Salary Range: $15.44 - $23.16 (Starting salary contingent upon directly related education and work experience).

The Kewa Pueblo Health Corporation (KPHC) is established for the purposes of carrying out the vision and mission of the Santo Domingo Health Center (KPHC).

The VISION OF KPHC is: “HEALTHY PEOPLE, HEALTHY COMMUNITY, HEALTHY LIFESTYLE” and the MISSION of KPHC is:
“ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE”.

PERFORMANCE EXPECTATIONS
In performance of their respective tasks and duties all employees of the Santo Domingo Health Center are expected to conform to the following:
• Uphold all principles of confidentiality and patient care to the fullest extent.
• Adhere to all professional and ethical behavior standards of the healthcare industry.
• Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
• Possess cultural awareness and sensitivity.
• Maintain a current insurable driver’s license.
• Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well as all applicable laws.

POSITION PURPOSE
The purpose of this position is to provide a full range of services related to contract health, business office, medical records, and clinic administration.

MINIMUM MANDATORY QUALIFICATIONS
Experience:
At least one year experience with hospital or healthcare accounting.
At least one year experience with a healthcare accounting system (RPMS).

Education:
High School Diploma or GED equivalent

Mandatory Knowledge, Skills, Abilities and Other Qualifications:
Knowledge of and the ability to apply the Alternate Resource regulations; P.L. 94-437, Title IV of Indian Health Care Improvement Act, Indian Health Service Policy and Regulations on Alternate Resources, CFR-42-36-21 (A) and 23 (F) and P.L. 99-272, Federal Medical Care Cost Recovery Act, Internal Control Policy and the Revenue Operations Manual. Knowledge of the total Alternate Resources Program operations, priorities and goals. 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 etc., associated with the various third party payers. Knowledge of ICD-9 and CPT 4 and HCPCS 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 UB-04 and CMS1500 billing forms submitted to third party payers. 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 (RPMS) and the accounts receivable management program. Keeps abreast of current changes in government regulations, collection laws, FTC ruling, third party procedures and internal procedures. Knowledge of billing functions, exporting clean billable claims to third party payers. Abstracting from the electronic health record and the resource and patient management system (RPMS) to applying the appropriate CPT-4, ICD-9, CDT-2, HCPCS codes for outpatient and inpatient encounter setting. 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 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 communications skills are required for training of staff on changes through continuing education and communication with medical staff. Knowledge and familiarity with the utilization review/compliance program rules and regulations and various aspects of compliance issues, special coding and billing issues. Incumbent may be required to work day, evening and holiday shift. A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. Knowledge of and have the ability to apply the Alternate Resource regulations; P.L. 94-437, Title IV of Indian Health Care Improvement Act, Indian Health Service Policy and Regulations on Alternate Resources, CFR-42-36-21 (A) and 23 (F) and P.L. 99-272, Federal Medical Care Cost Recovery Act, Internal Control Policy and the Revenue Operations Manual. Knowledge of the total Alternate Resources Program operations, priorities and goals. Knowledge of all third party claims submission process and ability to keep current on changes in policies, regulations of eligibility. 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 (RPMS) and the accounts receivable management program. Keeps abreast of current changes in government regulations, collection laws, FTC ruling, third party procedures and internal procedures.

PREFERRED QUALIFICATIONS
• Associate’s Degree in a related field
• Bilingual skills in English and the Keres native language
• Prior experience working with Indian Health Services (IHS), a Tribe or Tribal organization

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES
1. 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 documentation and contact the appropriate individuals to resolve problems.

2. Provides technical assistance with processing and maintaining CPT4 coding, abstraction of the complete chart (outpatient, inpatient) and compliance enforcement of all regulatory requirements. Review, analyze CPT4 coding, abstracting and compile data, maintain and identify potential risk areas in medical record. All information will be used for manual data analysis for the business office, utilization review, medical records and administration.

3. Searches and abstracts all CPT4 coding, operative and therapeutic and all other pertinent data from the medical record in order to identify and document appropriate patient care and other information necessary for billing.

4. Complies with all coding guidelines and rules and regulations of third party payers. Adheres to the internal control policy of approving billable encounters within 48 hours of outpatient claims.

5. 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 CPT4 and HCPCS 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.

6.Identifies inconsistencies and/or discrepancies in medical documentation by notifying the appropriate providers and/or 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 Health Center's policy and utilization review/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.

7. Maintains accounts by reviewing documents to verify accounting data as necessary, entering data into the system. Reconciles accounts comparing account balance with related data to assure agreement, reviewing records and source documents to identify the sources of discrepancies and determining the entries required to bring the account to balance.  Prepares reports reflecting the examinations made, discrepancies noted and the corrective entries required for adjusting accounts.

8. As part of maintaining accounts, Incumbent is responsible for daily batching, posting, adjustments and denials within 72 hours after receipt of payment; follows up on all denied claims and notifies Supervisor of patterns in denials and requests. Answers all correspondence requesting additional Provider or Patient information; forwards all Billing requests to the established billing person.  Additionally, rolls all payments to a secondary/tertiary payer and notifies the Billing person of the need to bill a secondary claim.

9. The incumbent is responsible for reviewing denials, adjustments and/or requests for additional information from Insurers, Medicare/Medicaid and routes the denials, adjustments, requests to the Billing person for correction/action.

10. Conducts aged claims follow-up every 45, 60 and 120+ days as assigned by the Business Manager or designee.  Claims are corrected and resubmitted, appeals prepared and sent within an established timeframe.  Maintains an aged account at or below the agencies acceptable percentile.  Submits Age Day List or accesses insurer portal to determine whether payments/adjustments were made; notifies the Billing clerk if claims were not received so claims can be resubmitted.

11. Prepares and maintains a weekly Accounts Receivable report keeping a zero balance of accounts posted, by running the Batch Statistical Report, Period Summary Report and Age Summary reports ; accountable for Unallocated and Refunded batches.

12. The incumbent prepares other internal and external reports for use in evaluating quantity, quality, and effectiveness of all collections. The incumbent maintains records of work accomplishments and time expended, preparing workload and production reports as required.  The incumbent assures that administrative and technical reports are compiled and prepared for the purpose of facility as well as department planning and evaluating.  The incumbent provides advice and recommendations to management for any operational improvements and/or deficiencies.

13. Assures alternate resource information is captured on all patients receiving services at this facility. The methodology includes but not limited to interviewing patients during their clinic visit/outpatient setting, sending insurance questionnaires to patients or calling patient, reviewing release of information, general and patient related insurance inquiries, reviewing administrative files, contacting alternate resources for claims information.

14. Incumbent must have knowledge of Billing requirements to determine if a claim was denied incorrectly based on the Diagnosis, coding, Medicaid Categories, and other erroneous denials.

15. Provides a monthly report to the Business Manager no later than the 1st of each month; the reports include, a PSR, TSR, ASM, BRRP for all Allowance Categories, Adjustments (ADJS).

16. Responsible for notifying Providers of additional documents required; obtaining signatures for continued practice at the Healthcare Center; requesting other documents as it may apply and increase the Revenue cycle.

17. Answers telephone and personal inquiries regarding payment, outstanding charges, eligibility, etc. Answers routine correspondence and compiles information and assist in the preparation of periodic and special reports concerning contract services to Area Office and Health Center Director.

18. Prepares routine correspondence when appropriate.

19. Perform other duties as assigned.

WORK ENVIRONMENT
Work environment:
The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. This position may be exposed to certain health risks that are inherent when working within a health center facility.

Physical demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear. There may be prolonged periods of sitting, keyboarding, and reading. The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors and staff. 

OTHER
There are a number of deadlines associated with this position. The employee must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.

Disclaimer: The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.