The Billing Specialist is responsible for third-party billing and accounts receivable data to maximize funds available for tribal health services. They audit, analyze, edit, and process medical insurance claims, monitor A/R, and ensure billing rules and regulations compliance, especially with the Medicare/Medicaid program. They also perform administrative duties such as tracking reimbursements, preparing billing documents, maintaining records, and working with IT on billing changes and updates.

Duties Include:

Third Party Billing/Accounts Receivable:

• Audit, analyze, edit, and process visits and charges for all billable health care services.
• Audit, download, and process electronic media claims and EFTs regularly.
• Monitor A/R.  Including research and rebill, all denied medical insurance claims.
• Reconcile monthly LabCorp invoice.
• Reconcile, process, and monitor all multiple coverage and subrogation claims.
• Print and mail any billing forms.
• Process workman’s comp. claims in coordination with the HR Department to ensure all pertinent data is gathered. 
• Participate in on- or off-the-job site training, meetings, workshops, or seminars related to third-party billing and other issues.
• Use One Health Port and access HMA to verify insurance coverage and check on denials.

Medicare/Medicaid Compliance: 

• Act as the Medicare Compliance Officer.
• Monitor OIG, Medicare, Medicaid, and other third-party coverage newsletters to ensure compliance with billing rules and regulations.
• Keep the NDC library up to date.
• Work directly with health clinic staff on billing, coding, and insurance compliance issues.

Administrative Duties:

• Monitor the Community Health Center fee schedule to ensure charges remain compatible with market trends and third-party contracted allowables.
• Process weekly third-party reimbursement deposit.
• Track and log third-party reimbursements due to the Social Services Department. 
• Provide a copy of the weekly third-party deposit spreadsheet to the Social Services Department accounting staff.
• Assist Tribal Administration with EFT agreements.
• Prepare and coordinate billing documents with Medical Records for subrogation, disability claims, etc.
• Enter alerts in NextGen to notify front desk staff of the need for updated third-party billing information. 
• Work with IT on third-party billing changes and updates as needed.
• Maintain all pertinent records in the office.
• Keep provider licenses and third-party coverage contracts up to date and set up with Provider Source “e-credentialing.” 
• Work with veterans' insurance eligibility, enrollment, and third-party billing/collection issues.
• Function as Insurance Administrative contact with HCA regarding MCO needs.

Remote Work:

• This position is eligible for alternative scheduling. The schedule must be discussed with and approved by the supervisor and director and may be subject to change depending on the role and department needs.

Other duties as assigned.

Education and Certifications:

• A High School Diploma or Graduate Equivalent Degree is required. Basic computer skills and the ability to learn Word, Excel, and other software programs are also needed.
• Proficiencywith medical and dental terminology required.
• Coding Certification preferred.
• Drivers License – Required
• First Aid/ CPR certification-Required

Experience:

• A minimum of two years of experience with third-party billing/accounts receivable and data entry procedures in a primary care clinic or similar setting is preferred.
• Thorough knowledge of CPT, HCPC, and ICD-10 coding preferred.
• A thorough understanding of Medicare, Medicaid, and other third-party coverage is preferred.
• Ability to analyze complex billing/data entry information.
• Ability to read and comprehend billing and coding manuals and instructions.
• Ability to educate healthcare staff on coding and billing issues.
• The ability to relay and represent patient third-party coverage issues to outside billing entities is imperative.
• Familiarity with personal computers is required. Prior experience with Electronic Practice Management software is also required. Knowledge of Word and spreadsheet software programs is also required.
• Ability to interact with others professionally and compassionately, maintain confidentiality, and work well as a team member. 

Physical Requirements:

• Regularly required to finger, handle, reach with hands and arms
• Frequently required to walk, sit, stand.
• Occasionally required to lift and move up to 25 pounds.
• Normal audio and visual acuity

Travel Requirements:

• Local, Statewide, and out-of-state travel may be required.