Billing Technician

The incumbent performs highly technical and specialized functions in coding, abstracting and billing functions. The employee reviews, analyzes, and codes diagnostic and procedural information that determines Medicare, Medicaid and private insurance payments. The primary function of this position is to perform ICD-10-CM, CPT and HCPCS coding for reimbursement.

• 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

ESSENTIAL DUTIES, FUNCTIONS & 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 documentation and contact the appropriate individuals to resolve problems.
• Determines the final diagnoses, ensuring assigned ICD-10 codes are at the highest level of specificity and procedures stated by the physicians or other health care providers are valid and complete.
• Quantitative analysis – Performs a comprehensive review for the record to assure the presence of all component parts such as: patient and record identification, signatures and dates where required, and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
• Qualitative analysis – Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established third party reimbursement agencies and special screening criteria.
• Keeps abreast of current changes in government regulations, collection laws, FTC ruling, third party procedures and internal procedures.
• Provides technical assistance with processing and maintaining CPT4 coding, abstraction of the complete chart (outpatient) 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.
• 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.
• Complies with all coding guidelines and rules and regulations of third party payers. Adheres to the internal control policy of approving billable encounters within 72 hours of outpatient claims. Position requires extreme accuracy and timeliness in all phases of work.
• 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.
• 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.
• ENSURES CLEAN ACCURATE CLAIMS ARE SUBMITTED PROMPTLY, FOLLOWING ESTABLISHED BILLING GUIDELINES BY THE FEDERAL/STATE/LOCAL GOVERNMENT, CMS, NM MEDICAID AND OTHER LOCAL PAYER REGULATIONS AND COMPLIANCE REQUIREMENTS.
• PREPARES AND/OR VERIFIES MEDICAID/MEDICARE ENROLLMENT OF PROVIDERS IN ORDER TO INSURE OPTIMAL BILLING POTENTIAL. NOTIFIES PROVIDER AND MANAGEMENT OF EXPIRED ENROLLMENT AND REVALIDATION.
• ACQUIRES NPI NUMBERS FROM PROVIDERS AND ASSIST PROVIDERS IN ACHIEVING NPI NUMBERS IF NOT AVAILABLE.
• PROVIDE ROSTER UPDATES TO MCO’S FOR PROPER BILLING CAPABILITIES.
• PROVIDES DAILY, WEEKLY AND MONTHLY REPORTS TO THE DIRECTOR OF BUSINESS REVENUE AND CHIEF FINANCIAL OFFICER.
• Performs other duties as assigned.

• High School Diploma or GED equivalent

• Three (3) years’ work experience in medical billing or coding.

• AAPC or AHIMA certified biller or medical coder with a minimum of CPB or CPC credential OR the ability to obtain certification within one (1) year of start date.

• Advance knowledge of medical terminology, time-based coding, abbreviations, techniques and surgical procedures; anatomy and physiology; major disease processes; pharmacology; and the metric system to identify specific clinical findings, to support existing diagnoses, or substantiate listing additional diagnoses in the medical record.
• Advance knowledge of medical codes involving selections of most accurate and description code using the ICD-10-CM, CPT and HCPCS, 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.
• Skill in correlating generalized observations/symptoms (vital signs, lab results, medications, etc.) to a stated diagnosis to assign the correct ICD-10,-CM code.
• Knowledge of all third party claims submission processes 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.
• Extensive knowledge of official coding conventions and rules established by the American Medical Association (AMA), and the Center for Medicare and Medicaid Services (CMS) for assignment of diagnostic and procedural codes.
• 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.
• Ability to establish and maintain relationships with the third party payer community necessary for resolution of outstanding claims.
• 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 billing functions, exporting clean billable claims to third party payers. Abstracting from the electronic health record to applying the appropriate CPT-4, ICD-10, CPT, HCPCS codes for outpatient and inpatient encounter setting.
• Ability to read and abstract physician office notes and procedure codes to apply correct ICD-10-CM, CPT, HCPCS Level II and modifier coding assignments.
• 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.
• Demonstrated knowledge of coding rules and regulations along with proficiency on issues regarding medical coding, compliance, and reimbursement under outpatient grouping systems.
• 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.
• Must have good math skills and effective communication skills. Must be knowledgeable of the fiscal requirements, policies, and procedures of federal, state, and tribal programs.
• Knowledge of the business use of computer hardware and software to ensure the effectiveness and quality of the processing and presentation of data. Requires skill in the use of a wide variety of office equipment including: computer, typewriter, calculator, facsimile, copy machine, and other office equipment as required. Must be able to follow instructions and work independently.
• Expertise in applying payer policy, Local Coverage Determinations (LCDs), and National Coverage Determination (NCDs) for successful claims submissions.
• An understanding of the life cycle of a medical claim and how to improve the revenue cycle.
• A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers.

• Prior experience working with Indian Health Services (IHS), a Tribe or Tribal Organization.
• Knowledge of NextGen Enterprise PM/EHR.