Medical Biller

Tohono O•Tucson, AZ

About The Position

Under general supervision, the Medical Biller examines, verifies, and maintains data used to process medical care claims for alternate-resource reimbursement and performs other third-party billing duties. The primary purpose is to process medical care claims accurately and promptly to secure reimbursement from third-party payers. The role includes reviewing claims for completeness and accuracy, obtaining missing information, and performing accounting, budget, and financial-management support related to medical billing. The incumbent manages claims from receipt through payer payment, including coding and abstracting medical records, preparing and submitting claims, following up on electronic transmissions, correcting rejected or suspended claims, maintaining patient-account documentation, and reconciling reports and control totals. Outpatient claims are to be billed within six business days of service, inpatient claims within ten days, and claims are to be submitted within 48 hours after all billing information becomes available. The position also maintains insurer and provider files, supports staff training on online insurance systems, and provides technical assistance with coding, abstraction, and regulatory compliance. The position may require temporary relocation to other TONHC facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center. Other job-related duties may be assigned, and the incumbent contributes to a team effort.

Requirements

High school diploma or General Education Diploma.
Two years of work experience in medical billing, third-party billing, accounting, budget, financial-management support, or equivalent.
Type at least 40 words per minute.
Knowledge of the Tohono O'odham culture, customs, and traditions.
Knowledge of accounting, budget, and financial-management regulations, practices, procedures, and policies related to medical billing and revenue-cycle operations.
Knowledge of hospital admitting procedures and documentation, clinic services, medical terminology, anatomy, common drugs, spelling, and medical abbreviations.
Knowledge of hospital and clinic operations, coordinating organizations, and applicable federal regulations and standards.
Knowledge of confidentiality requirements, including the Privacy Act of 1974 and HIPAA, as well as FOIA and other protections for confidential health information.
Knowledge of complex billing processes and related billing, collections, accounting, budget, eligibility, claims, follow-up, adjustment, and automated systems.
Knowledge of alternate-reimbursement policies and regulations, Medicare and Medicaid requirements, third-party payer rules, and applicable federal laws and Indian Health Service policies.
Knowledge of the Resource Patient Management System (RPMS), Third Party Billing program, Utilization Review System, online input equipment, and automated electronic billing systems.
Knowledge of ICD-10 and CPT-4/HCPCS coding, diagnostic and procedural sequencing, Uniform Hospital Discharge Data, and DRG assignments.
Knowledge of compliance rules and issues relating to hospital coding and billing.
Excellent communication skills to train staff on changes and communicate with medical staff.
Typing and basic computer skills, including word processing, calculator, spreadsheet, and database software.
Ability to interpret and resolve issues using system-monitoring reports and UB-92 and HCFA-1500 billing forms.
Ability to analyze complex medical and regulatory information and determine an appropriate billing method.
Ability to maintain effective working relationships with employees, clients, patients, and the general public; exercise tact; and provide superior customer service.
Ability to manage multiple tasks, meet deadlines, exercise independent judgment, follow verbal and written instructions, communicate effectively, and maintain confidentiality.
Upon recommendation for hire, complete a criminal background check, National FBI fingerprint check, and 39-month driving-record review to determine suitability for employment.
May be required to possess and maintain a valid driver's license with no DUIs or major traffic citations within the previous three years. If required to drive program vehicles, meet the Tohono O'odham Nation tribal employer's insurance requirements for a driver's permit.
Depending on department needs, may be required to demonstrate fluency in both Tohono O'odham and English as a condition of employment.

Responsibilities

Receive and examine alternate-resource claims for completeness and supporting documentation, and manage claims through third-party payer payment.
Verify health claim numbers, authorized amounts, and whether billed services are allowed under applicable regulations and guidance.
Identify errors, omissions, and duplicate documentation; contact relevant individuals to resolve issues before claims are approved and submitted.
Audit evaluation and management documentation, abstract medical records, and assign appropriate CPT/HCPCS codes using applicable AMA, ADA, and HCFA coding conventions and rules.
Search medical records for operative, therapeutic, and other relevant information to identify and document patient care and select accurate CPT/HCPCS codes.
Meet billing timelines: bill outpatient claims within six business days of service and inpatient claims within ten days; submit claims within 48 hours after all billing information is available.
Batch bills and prepare invoices and patient listings for submission to Blue Cross/Blue Shield Fiscal Intermediary, Medicare, Medicaid, private insurers, and other alternate resources.
Maintain transmittal logs for electronically transmitted claims and follow up on electronic submissions.
Serve as a contact for questions or problems involving claims processing and coding; recommend process changes to address recurring problems and expedite work.
Verify claims processing and control totals; review reports and listings for balance, format, sequence, and valid data.
Maintain timely filing records for third-party documents, remittance advice, and payer transmittals regarding coverage or billing-procedure changes.
Provide technical assistance with CPT coding, outpatient chart abstraction, and regulatory compliance; identify documentation discrepancies and notify providers and relevant departments to support complete charge capture.
Consult with physicians, laboratory personnel, and other departments regarding regulations, compliance requirements, and preparation of itemized billing.
Add and edit insurers in the insurer file, complete claim formats, and coordinate with Patient Registration to maintain the file.
Maintain and control unbilled claims for an assigned patient-receivables section and review system-generated reports daily to identify claims ready for billing.
Correct errors on rejected or suspended claims previously submitted to third-party payers, intermediaries, or patients according to hospital policy and procedures.
Document account activity in patient financial folders, including billing dates and contacts, and provide the supervisor with an accurate accounting of assigned claims.
Submit a daily billing productivity report showing beginning inventory, claims billed, and remaining balance at the end of the shift.
Maintain provider files, keep provider licenses current, and complete provider applications for NPI, AHCCCS, and Medicare numbers.
Manage access to online insurance data, including usernames and passwords, and train users on online systems.
Use word-processing and other automated equipment to extract, list, transmit, print, format, file, and retrieve information.
Perform other job-related duties as assigned and contribute to a team effort.