Billing Specialist II

Billing Specialist II

Klamath Tribal Health & Family Services (KTHFS) is a tribally-operated health facility offering direct medical, dental, pharmacy, behavioral health, and non-emergent transportation services to Native Americans and Alaska Natives residing within the service delivery area. The Billing Specialist is responsible for managing patient accounts in a complex, multi-disciplinary Business Office environment. The incumbent shall cross-train with other members of the Klamath Tribal Health Business Office Staff and shall participate in all functions of the coding and billing cycle, to include: daily review of encounters, analyzing chart notes and assuring the appropriate service codes are utilized, data entry of encounter forms, posting charges into the computer system, perform claims review, claims submission, timely billing, follow-up and collection of all accounts, payment posting, claims audit and research. The incumbent shall also function as a resource for clinic providers and staff and will assist with coding and billing questions, and quality assurance activities.

Major duties and responsibilities include:

• Daily review, analyze, and interpret patient ambulatory EHR and/or paper encounter coding and corresponding chart note documentation and determine that the appropriate diagnostic and procedural codes are used and appropriately reflected in the chart note for code assignment as outlined by the CMS guidelines. Assuring that medical/dental necessity billing guidelines are met.
• Ensure the appropriate service codes are applied in the billing record that corresponds to the documentation referenced in the chart note or on the encounter forms. Ensure that the appropriate ICD-10, CPT, HCPCS, CDT coding conventions have been used for services provided by all health service types within KTHFS, including but not limited to: medical, dental, behavioral health and transportation.
• Work with providers and nursing staff to clarify documentation in the EHR system if needed. Including correlating anatomical and physiological processes of a diagnosis to assure the most accurate ICD-10 code(s) are used. Advise supervisor and clinicians of deficiencies to support charge capture of all billable services.
• Prepare and submit clean claims (electronic or paper) to primary/secondary insurance carriers including Medicaid, Medicare (Part A&B), and private insurance companies.
• Maintain compliance with billing regulations: including Medicaid (DMAP), Medicare (Parts A&B, DME), Private Insurance Carriers (i.e. HMA, BCBS, ODS, etc.).
• Payment post insurance checks or EFTs, which includes: verifying the checks or EFTs that have been receipted in the KTHFS Operations Support System, batching the checks or EFTs into the current billing system, and then accurately posting the payments into the current billing system.
• Process refunds for any overpayments made to KTHFS. Monitor claims payment and promptly request POs for refunds to insurance companies, or perform electronic claim adjustments per payer requirements, for any overpayments made on claims. The refund will also be processed to reflect the claim refund in the practice management system.
• Process No-Pay EOBs, applying an adjustment, create billing notes and claim follow-up. This includes the appeal of insurance claims that have been wrongfully paid or denied, contacting insurance companies by phone to obtain information concerning extent of benefits and/or settle unpaid claims and providing any additional information requested by insurance companies for the processing of submitted claims.
• Record in NextGen system all claims related phone calls, correspondence, and activities related to each patient account.
• Maintain current filing system for encounters, POs, & etc.; process daily incoming mail and correspondence for review, completion, and filing.
• Communicate regularly with Patient Registration Staff and record patient benefit effective/term date(s) into the practice management system as needed.
• Create electronic batches to submit to clearinghouse in Nextgen and reconcile to claims spreadsheet including follow up on electronic claims receipt by payer. Correct any claims before archiving the file in the clearinghouse.
• Work outstanding A/R by reviewing, rebilling, and adjusting accounts to ensure accurate and thorough billing of claims, by running reports and working on claims. Track and monitor claims processing, ensure timely follow-up for the payment of bills; Identify, and resolve all outstanding/pending claims.
• Monitor the Business Office outlook inbox regularly and back bill any claims and/or adjust claims where applicable.
• Run specific reports as identified below:
• To be ran and worked weekly - Pending Charges Report, Unbilled Encounters, Paper Claims printed, Clearinghouse Reports (claims denied, outstanding claims, claims removed, claims rejected)
• Biweekly reports - Kept Appointments with No Encounters report, Aging Reports, and maintain up to date reports making sure all old billing is addressed.
• Establish and maintain an effective working relationship with public and private payers; identify potential problems that could cause interruptions to cash flows.
• Participate in yearly chart audit activities for quality assurance purposes; document results in report format, as needed, to be able to have reviewed by Clinical Director and Compliance Officer.
• Attend coding seminars, meetings, or other training opportunities to keep abreast of changes in the profession.
• Like all employees of the Klamath Tribes, the incumbent will be called upon to accomplish other tasks that may not be directly related to this position, but are integral to the Klamath Tribes' broader functions, including but not limited to, assisting during Tribal sponsored cultural, traditional, or community events that enable the successful operation of programs and practices of The Klamath Tribes as aligned with The Klamath Tribes' Mission Statement. Some of these tasks may be scheduled outside of regular work hours, if necessary.

Supervisory controls include:

• Work under the supervision of the Business Office Manager, who provides general instructions. Work is assigned in terms of functional/organizational objectives. The manager assists with unusual situations that do not have clear precedents.
• Employee must be able to work with minimal supervision, using initiative and judgement in setting priorities to meet the demands of the workload. Work is performed within the purview of laws, and regulations. The manager will review work regularly for quality and compliance with established policies and procedures and payer guidelines.

Knowledge, skills, abilities include:

• Technical knowledge, skill, and understanding of the American Medical Association developed CPT coding system in order to acquire, interpret, and resolve problems based on information derived from system monitoring reports to be carried over to the required billing forms.
• Technical knowledge, skill, and understanding of the concepts of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for classification of diseases and/or procedures.
• Knowledge and understanding of CDT dental coding system.
• Basic knowledge and understanding of HCPCS coding.
• Knowledge of mental health and alcohol and drug coding and billing is desirable.
• Ability to work with minimal supervision, using initiative and judgment in setting priorities to meet the demands of the workload while adhering to the insurance rules and regulations that relate to coding and billing.
• The knowledge of and/or the ability to learn the billing guidelines as they pertain to FQHC/Tribal Health Clinics.
• Knowledge of established procedures, required claim forms (both paper and electronic) associated with the various health insurance programs.
• In-depth knowledge of Medicaid (OARs, Rulebooks).
• In-depth knowledge of Medicare Part A & B billing regulations.
• Knowledge of medical terminology.
• Knowledge of claims review, account auditing, and quality assurance.
• The ability of tracking, handling, and completing multiple projects.
• Ability to communicate well (both orally and in writing) and work effectively with other employees, managers, and administrators. This person should be able to express themselves in a clear and concise manner for the purposes of correspondence, reports and instructions, as well as for obtaining and conveying information to ensure a cooperative working relationship with all staff.
• Willingness to maintain expertise to keep current with changes in procedure and diagnosis coding and third-party payer reimbursement policies through continuing education.
• Above average ability to work with numbers and set standards in order to assure proper payment and adjustment posting.
• Must be dependable, thorough, accurate, well-organized and detail oriented.
• Ability to maintain strict confidentiality of medical records and adhere to the standards for health record-keeping, HIPAA and Privacy Act requirements.
• Conduct self in accordance with KTH&FS Employee Policy & Procedure Manual.

Qualifications, experience, education include:

• Minimum Qualifications:
• REQUIRED to possess a High School Diploma or Equivalent. (Must submit copy of diploma or transcripts with application.)
• REQUIRED Must have one of the following certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Registered Medical Coder (RMC), RHIA, RHIT or an Associate's degree in Medical Office Systems or Health Information Management.
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