Primary Function     

The incumbent performs highly technical and specialized functions for the Cherokee Indian Hospital Authority. The employee reviews and analyzes diagnostic and procedural information that determines Medicare, Medicaid and private insurance payments. The primary function of this position is to analyze the ICD-10-CM, CPT and HCPCS coding for reimbursement. The Revenue Cycle Management Office functions are a primary source for data and information used in health care today, and promotes provider/patient continuity, accurate database information, and the ability to optimize reimbursement. The Revenue Cycle Management office functions also ensure compliance with established guidelines, third party reimbursement policies, US Government regulations and accreditation guidelines.          

Job Duties and Responsibilities

• Quantitative analysis – Performs a comprehensive analysis of 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 – Analyzes the record for documentation consistency and adequacy. Ensures that all diagnoses accurately reflect the care and treatment rendered. Reviews the records for compliance with established third-party reimbursement agencies and special screening criteria.
• The incumbent analyzes the coding of ICD-10-CM/CPT/HCPCS codes to diagnosis and procedure for documented information. Assures the final diagnosis and operative procedures as stated by coding are valid and complete for billing.
• Operate RPMS peripheral equipment (CRT and printer) for the purpose of key-entering data for the process of updating of changing health summaries for patient information files and of exporting said data.
• Responsible for the accurate and timely preparation and submission of claims to third party payers, intermediaries, and responsible parties according to established hospital policy and procedures.
• Maintenance and control of unbilled claims for an assigned section of the patient receivables. Works claims in a timely manner and maintain supporting documentation. Does research for clarification of alternate resources and making the necessary correction to the patient chart for future billing. 
• Analyzes system generated reports daily/weekly to identify claims that are ready for billing. Notify Medical Coders of missing information needed for medical necessity where applicable.
• Responsible for the follow-up process on claims that have not paid (rejected, suspended, denied) for an assigned section of the patient receivables, which includes mailing statements, filing appeals, making phone calls to the responsible party or insurance company, corresponding with our collections agency, performing error corrections, etc. according to hospital policy and procedures.
• Be able to identify patients that may have other health insurance for billing sequence.  Know the different reasons on how a patient is eligible for Medicare to ensure the accurate Medicare Secondary Payer (MSP) code is used in billing for reimbursement.
• Review and analyze payment negotiation requests from insurance companies and advise on policy of accepting the discount request.   Obtain final approval from the Revenue Cycle Manager as to an agreement on a discount.
• Must, be detailed oriented and have great organizational and time management skills.  Perform all duties according to established procedures and tribal policy.   It is imperative to keep up to date with changes in insurance guidelines, procedures and reporting to assure maximum reimbursement.
• Expected to be professional and present as a role model to co-workers and the organization.  Offer suggestions to enhance the Revenue Cycle Management office functions.
• Performs other duties assigned.

Education /Experience

• This is an entry-level position.  
• Completion of high school or equivalent is required. 
• Basic medical office experience is preferred.  
• RHIA, RHIT, CPC, CPB, CCS, CCS-P or NCICS certification is preferred and is required within two years from date of hire.
• This position will be learning the Revenue Cycle Office process and utilizing CPT and HCPCS codes. 
• Enroll in continuing education courses to maintain certification is required.
• Twelve to Eighteen months would be required to become proficient in most phases of the job.
• Must possess a valid North Carolina driver’s license       

Job Knowledge

• Limited knowledge of medical terminology, abbreviations, techniques and surgical procedures; anatomy and physiology; major disease processes; pharmacology; and the metric system to identify specific clinical findings, to support existing diagnosis, or substantiate listing additional diagnosis in the medical record.
• Limited knowledge of medical codes involving selections of most accurate code using the ICD-10-CM, CPT, HCPCS, and the official coding guidelines and for billing of third-party resources.  Interpret and resolve problems based on information derived from system monitoring reports and the UB04, HCFA-1500, ADA2006 billing forms submitted to third party payer.
• Limited 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.
• Limited knowledge of and 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.
• Limited knowledge of ICD-10-CM, CPT, HCPCS coding terms.
• 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. 
• Requires 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.     

Complexity of Duties            

Duties are highly complex, varied, require planning and coordinating several activities at one time, and demand the use of critical thinking, problem solving skills and analysis of data and circumstances to develop appropriate actions. Subject to frequent interruptions, in person and by phone, which require varied response.  

Contact with Others 

Internal contacts occur on a regular basis with departmental personnel. External contacts include clients, families, health professionals, and general tribal population, as well as other tribal entities. Purpose for contacts is for the exchange of information requires tact, courtesy, and professional decorum. Contacts include agencies both federal and state including Indian Health Service, Medicaid, Medicare, and other private insurance companies, attorneys, auditors, and clearing house contractor.   Requires the ability to organize work and deal effectively with the public and federal, state, and tribal agencies.

Consistently demonstrates superior customer service skills to patients/customers by displaying Spotlight on Success I CARE behaviors and skills. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service. 

Confidential Data     

Has access to all departmental files, memos, financial records and medical records, which are confidential. Must, adhere to all tribal, IHS, and CIHA confidentiality policies and procedures, as well as the Privacy Act of 1974 and the HIPAA regulations, in the performance of duties.

Mental /Visual /Physical       

Concentration varies depending on the tasks. High levels of mental concentration are required. Must handle multiple tasks simultaneously and is subject to frequent interruptions. Physical effort requires sitting and reaching with hands and arms. Manual dexterity, visual acuity, and the ability to speak and hear are required.

Environment  

Work is performed in normal business office environment, with occasional travel required.

Supervision Received            

Work under the general direction of the Billing Analyst Supervisor. Has latitude for the exercise of initiatives, discretion, and independent judgment within the Cherokee Indian Hospital Authority.

Responsibility for Accuracy

Review of work and subsequent procedures would detect most significant errors of job functions. However, errors that are more serious could result in inefficient operations and loss of revenue and audit non-compliance.

Because information in the medical record is the basis for reimbursement as well as clinical decision-making, coding entries must be complete and accurate. The amount of reimbursement depends on the correct coding of diagnoses and procedures and appropriate DRG/APC assignment. The work has a direct effect on medical record keeping and a direct impact on the accuracy, documentation, timeliness, reliability, and acceptability of information in the medical record services.

Work has considerable impact on the accreditation status of the hospital, quality of patient care, reliability of research data, compliance and the maximization of Third-Party reimbursement.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.