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Practitioner Data and Claims Administrator
at Pacific Clinics
Practitioner Data and Claims Administrator
The Practitioner Data and Claims Administrator is responsible for leading, coordinating, monitoring, and maintaining the practitioners’ license, NPI and Taxonomy data in 6 different systems. In addition, this position is responsible for using electronic systems to analyze, correct and submit claims that were on-hold or contained inaccurate practitioner information.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Reviews and analyzes practitioner certification applications and accompanying documents, to ensure applicant eligibility is obtained.
- Verifies providers taxonomy codes and scope of practice; determines and identifies Medicare certifiable providers and Medicare enrollment issues.
- Prepares certification file for completion and presentation, ensuring file completion within time periods specified.
- Identifies application issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
- Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
- Responds to inquiries from other organizations, interfaces with internal and external customer on day-to-day certifications and privilege issues as they arise.
- Monitors the initial, update and expiration process for all certified staff, ensuring compliance with regulatory bodies, as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.
- Facilitates new employee orientation meeting to assist in provider application process and NPI registration, EHRS user account setup, etc.
- Submits all applications and rendering provider request, information update or terminiation request, to appropriate departments such as LAC DMH, Medicare certification unit, in a timely manner.
- Establishes and maintains a system to monitor and track application status regularly. Provides regular updates to supervisor regarding processing delays by DMH.
- Releases claims once rendering provider requests and applications have been processed.
- Collaborates with program HR Liaisons and other departments to ensure completion of assigned tasks.
- Retrieves and reviews claims denial and error reports. Researches and resolves denied/rejected claims that are related to rendering provider setup errors.
- Reviews, tracks and monitors all electronic systems to ensure successful submission of claims.
- Consults with supervisor regarding recurring issues and escalate resolution to appropriate party.
- Attend job related meetings and trainings.
- Attend and participate in department activities and staff meetings, providing clear and useful input on department procedures and targets.
- Provide backup support within the team when requested.
- Follow HIPAA policies.
- Perform all duties and work projects as assigned.
- Report to work on time and maintain reliable and regular attendance.
- Willing to work overtime during weekdays and weekends (Saturday and/or Sunday) when requested.
- Communicate effectively in a culturally competent and diverse consumer population and promotes favorable interaction with managers, co-workers and others.
- Performs other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Initiates and maintain professional interactions and communication with Clinics’ employees and/or others.
Participates as part of a multidisciplinary team and interacts with all levels of organizational staff and management; outside auditors and/or Agency vendors.
Maintain professional and effective working relationships, following all policies and procedures and approaching challenges with a proactive and positive attitude. Develop strong, trusted relationships with colleagues and customers.
Maintain the confidentiality of all business documents and correspondence.
Model Pacific Clinics’ approach, mission, and core values in all communication and correspondence.
Participate as part of a multicultural team, being sensitive to the cultural and linguistic needs of the clients and families served.
KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:
- Knowledge of healthcare billing and provider credential.
- Knowledge of DMH and Medicare rendering provider registration standards.
- Knowledge of National Provider Identifier (NPI) Standard and Taxonomy Code descriptions.
- Knowledge of county and State laws and regulations pertaining to service providers.
- Knowledge of all Provider’s Medical Staff Bylaws, and credentialing policies.
- Prefer knowledge of an Electronic Health Record System (EHRS) used in Healthcare for billing clinical services; preferably in Behavioral Healthcare.
- Skilled in using of Windows file system, Microsoft Word, and Outlook, with intermediate proficiency, Microsoft Access and Microsoft Excel, with moderate proficiency.
- Skilled in speedy and accurate computer data entry with the ability to use a computer keyboard proficiently, above 35 wpm.
- Skilled in use of NPI’s, taxonomies, and provider licensing.
- Skilled in navigation of multiple systems in parallel.
- Skilled in making decisions and using good judgment, dealing with ambiguity and change, and producing high quality work.
- Skilled in deductive reasoning, data analysis, problem solving, multi-tasking, completing repetitive tasks with accuracy, and improvising with a creative approach to problems and obstacles.
- Skilled in being very detail and results oriented, approaching tasks methodically, following through on projects to achieve results, being organized and prioritizing competing deliverables.
- Skilled in delivering work on time, and on a schedule.
- Skilled in accurate data entry and documentation.
- Skilled in communication with senior staff as well as line staff.
- Skilled in customer service.
- Skilled in professional verbal & written communication.
- Ability to navigate electronic systems to assure and confirm providers credentials.
- Ability to problem solve independently, organize and prioritize work and complete repetitive tasks with accuracy.
- Ability to follow detailed instructions, prioritize extremely time sensitive documentation submissions; must be flexible, organized, and conscious of these timelines.
- Ability to communicate effectively with a competent and diverse population and promote favorable interaction with managers, co-workers, subordinates and others; both orally and in writing
- Ability to adapt and be flexible in a rapidly changing environment, patient, accountable, proactive, and take initiative and work effectively on a team
- Ability to foster a cooperative work environment
- Ability and willingness to learn new topics, systems, and methods
- Ability to independently problem solve as well as analyze and resolve complex issues related to billing issues
- Ability to work with minimal supervision
EDUCATION and EXPERIENCE REQUIREMENTS:
- High school diploma or G.E.D with (3) three years direct medical or psychiatric billing experience.
- Direct experience billing, rebilling error corrections and reconciling patient billing accounts.
- Typing 35 wpm with accuracy required.
- Must possess a valid California driver's license and maintain an insurable driving record under the clinics' liability policy (if driving two or more times per week on company business) OR if driving is not required, demonstrated ability to use public transportation or other means to travel between sites, if requested.
While performing the duties of this job the employee is frequently required to stand or sit. The employee is required to use hands to produce records and/or documentation in manual or electronic format. The employee must regularly lift and/or move up to 5 pounds and occasionally move or lift up to 10 pounds.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
While performing the duties of this job, the employee is occasionally exposed to moving mechanical parts and outside weather conditions. The noise level in the work environment is usually moderate. Local business travel is required.
A review of this description has excluded the marginal functions of the position that are incidental to job performance of the fundamental job duties. All duties and requirements are essential job functions.
This job description in no way states or implies that these are the only duties to be performed by this employee. The employee will be required to follow any other instructions and to perform any other duties requested by his or her Manager and/or Supervisor.