THIRD PARTY BILLING TECHNICIAN
FT/REGULAR
NON-EMEMPT
LEVEL 9
SALARY: 22.67
GENERAL DEFINITION: The primary responsibility of this position is to manage medical billing processes, resolving claim issues, and ensuring timely and accurate reimbursement.
SUPERVISION RECEIVED: Work is performed under the general supervision of the Finance Director.
SUPERVISION EXERCISED: No supervisory duties.
DUTIES:
Program and systems management.
- Manages third party billing program operations, including bookkeeping, information management, filing systems, and related administrative services.
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Develop and implement procedures for the retention, protection, retrieval, transfer, and disposal of patient billing records.
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Operate, maintain, and update all automated electronic billing systems to ensure accurate, efficient and compliant processing.
- Prepare reports, summaries, program budgets, and billing forms, responds to inquiries, correspondence, and memorandums.
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Coordinate with immediate supervisor and Finance Director to establish and maintain third-party billing operating policies and procedures.
Claims Processing and Billing Operations.
- Prepare and submit accurate and timely Medicaid claims for health-related services.
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Process electronic claims to health insurance carriers for services provided to eligible patients
- Input data and prepare billing documentation for Medicare, Medicaid and Private Insurance.
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Reviews medical records to apply appropriate CPT, ICD-10, and HCPCS coding, for billing accuracy.
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Correct and process rejected claims.
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Research and resolve billing discrepancies.
- Bill out all services to Medicare/Medicaid and all Manage care.
- Contacts health care providers and other departments within the organization for follow-up and additional information as needed.
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Retrieves and researches medical records on patients from referring department
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Research patient records, identifies incorrect or missing medical information required to prepare a valid insurance billing claim when data received is incomplete.
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Monitor Works closely with department program managers to correct inconsistencies in accounts receivable and ensure the validity of patient charges.
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Research and follows up on denied or rejected claims to ensure maximum reimbursement to the organization.
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Collaborates with medical benefits help desks to resolve claim issues within specified time frames.
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Maintains billing accounts to ensure accuracy and validity of patient charges, which make up a significant portion of the accounts receivable.
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Ensures patient data is accurate to support proper billing documentation.
- Develops, updates, and maintains current policies and procedures.
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Examines Explanation of Benefits (EOBs) to confirm correct claims payment.
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Verifies Medicaid eligibility for all patients through the New Mexico Medicaid Provider Portal.
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Safeguards patient confidentiality in compliance with HIPAA Privacy regulations.
Presumptive Eligibility/Medicaid Assistance Duties.
- Acts as a Presumptive Eligibility (PE)/Medicaid On-Site Applicant Assistant (MOSAA) Determiner.
- Screens and enrolls eligible qualified individuals for Presumptive Medicaid eligibility.
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Assist applicants in applying for on-going Medicaid coverage.
- Adheres to PE Determiner standards, Code of Conduct, and HIPAA regulations.
Financial and Reporting support.
- Monitors operational and program-related issues and communicates findings as needed.
- Assists Finance Director with budget preparation, audits, revenue projections, and account tracking.
- Generates monthly 60-90 day aging report to track unpaid claims and ensure timely follow-up.
- Resubmits denied or unpaid claims promptly, often within the same day.
- Manages and tracks unbilled claims within assigned patient accounts.
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Reports unbillable claims monthly to supervisors, including detailed explanations.
- Analyzes patient and billing date to improve reimbursement outcomes and support research efforts.
- Ensures complies with all applicable tribal, federal, state, county, and regulatory requirements related to medical billing and patient confidentiality.
Performs other duties as assigned.
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Cross trained in other positions in the billing department.
- Regularly reviews Medicare transmittals and Medlearn updates to stay current with billing guidelines.
MINIMUM QUALIFICATIONS
KNOWLEDGE, SKILLS, AND ABILITIES: Knowledge of medical billing claims processes, insurance claims, and accounts receivable management. Knowledge of HCPCS and ICD-10 coding standards and billing practices. Knowledge of health insurance policies and procedures. Knowledge of medical terminology and basic medical coding. Knowledge of procedures in business communications, accounting and records management. Knowledge of Medicaid, Medicare, and third party billing policies and procedures, including eligibility verification. Knowledge of Explanation of Benefits (EOBs) and claims adjudication procedures. Knowledge of Resource Patient Management System RPMS and EHR systems. Knowledge in management systems and administrative processes. Ability to operate all automatic electronic billing systems. Excellent communication skills are required for training of staff. Knowledge of software applications and financial management systems. Knowledge HIPAA Privacy Rules and patient confidentiality standards. Understanding of revenue cycle management and aging reports analysis. Familiarity with the New Mexico Medicaid Provider Portal and Presumptive Eligibility processes (preferred). Strong analytical and problem-solving skills for researching and resolving claim issues. Attention to detail in reviewing billing data, coding, and reimbursements. Ability to communicate effectively orally and in writing. Ability to maintain confidentiality. Ability to utilize a computer by creating and maintaining databases. Ability to work independently. Ability to exercise sound and rational judgment. Ability to successfully and effectively function under multiple deadlines and task timelines. Skillful in developing positive customer relations and providing excellent customer service.
EDUCATION AND EXPERIENCE: Associate degree in a health Information Management, Medical Billing and Coding, Healthcare Administration or related field with four (4) years’ experience, preferably as a Medical Billing Specialist or Coder; OR High School diploma or GED with six (6) years of progressively responsible work experience in a health care facility as Billing Clerk or equivalent.
LICENSE AND CERTIFICATION: Valid New Mexico Driver's License with no DWI/DUI convictions within the past three (3) years. Driving is not an essential part of the duties.
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Certification as Presumptive Eligibility Determiner (PED) must obtain within six (6) months of employment.
- Must complete and maintain recognized CMS Biller/Coder.
PHYSICALDEMANDS: The work is sedentary. Typically, the employee may sit comfortably to do the work. However, there may be some walking, standing, bending, carrying of light items, driving an automobile, etc. No special physical demands are required to perform the work. Regular exposure to favorable conditions such as those found in a normal office.
SPECIAL WORKING CONDITIONS: Position is subject to pre-employment drug testing. Position is Safety Sensitive and will be subject to random drug screening for duration of employment, in compliance with the Pueblo of Zuni Drug Free Workplace Policy. Must successfully pass a thorough character background investigation including FBI Fingerprint Check. May be required to work evening and weekends. Must be able to cope with stressful situations and provide effective customer service.
