3019 - TRC Clinical Billing - Clinical Svs Admin
In conjunction with the AED of Clinical Operations , will provide guidance, support, and oversight to Patient Access Representatives’ as well as others as assigned. To ensure an exemplary customer service experience is provided at all sites and with all customers. To optimize reimbursement mechanisms and minimize the potential for denials, while remaining sensitive to the needs of all customers.
To oversee insurance contacting, credentialing and quality for designated clinic environments. To oversee the development and ongoing maintenance processes of all insurance contracts in order to keep pace with ever-changing contractual arrangements, incentive terms to ensure consistent management of all proposals and contracts. Responsible for all aspects of the credentialing, re-credentialing and privileging processes for all designated providers. Responsible to oversee all aspects of the quality assurance quality improvement processes in designated areas.
Requirements: Requires knowledge and experience credentialing process, insurance contacting and quality assurance principles. In addition to data collection and information processes and systems along with knowledge of policy and procedure compliance. Proficiency in utilizing and interpreting financial models and analyses. Must possess a comprehensive knowledge and understanding of current laws and regulations related to accounts receivable and insurance
billing for clinical services (i.e. Medicare, Medicaid, and other third-party insurances); Experience in applying organizational standards when developing requests for proposals, negotiating terms and drafting contracts. Ability to systematically analyze complex problems, draw relevant conclusions and implement appropriate solutions.
Requirements: Advanced computer literacy including, database management, spreadsheet, word processing internet and e-mail, in addition to experience with Electronic Health Records systems
Strong verbal and written skills and ability to convey complex information in a way that others can readily follow. Must be comfortable providing guidance, direction, and feedback to others; Ability to communicate effectively with individuals at all levels, internally and externally, is critical; Excellent negotiating and persuasive skills, both in one-on one and group situations. Ability to organize and prioritize work and manage multiple priorities. Excellent verbal and written communication skills including, letters, memos and emails. Excellent attention to detail. Ability to research and analyze data. Ability to work independently with minimal supervision. Ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization excellent interpretation and problem solving skills; demonstrated ability to interpret policies and regulations, and to appropriately answer questions. Ability to work in a professional manner, both independently and with others in a team environment. Physical condition or reasonable accommodation commensurate with demands of the job
Bachelor’s degree in business, healthcare management or related field. Master’s Degree Preferred.
Experience and certifications (i.e. Certified Provider Credentialing Specialist) can be substituted for degree on a year-for-year basis.
Proven supervisory experience strongly preferred.
Valid NYS driver’s license with driving record acceptable to agency insurance carrier, use of a personal vehicle or equivalent accommodations, and willingness to travel for work is required.
Responsible for providing supervision of assigned revenue cycle team members including functions, which includes but is not limited to:
Hiring,firing, discipline, performance evaluation, in-service education and training, and ensuring that there are adequate numbers of staff to fulfill assigned responsibilities.
Coordinating staff orientation with the Staff Training and Development Center and ensuring new-hires and existing staff receive and complete ongoing trainings.
Overseeing all aspects of assigned workforce, including timely completion of personnel-related paperwork, disciplinary actions, and other related matters
Ensuring coverage and cross training of all assigned staff.
Performs all other related duties as needed or assigned..
Monitors and improves front desk/ registration entry timeliness, accuracy, and productivity,in order to optimize cash flow and customer satisfaction
Ensures proper protocols are followed by patient representative staff, including but not limited to, new patient registration and procedure entry
Uses multiple Electronic Health Records and ensure training and competency in system utilization with all team members
Ensures Patient Access Representative staff have the tools needed to complete their required duties in a smooth and effective manner
Ensures access to cash daily and oversees the reconciliation of cash and receipts according to all standards protocols and agencies policy
Ensures operations perform within or better than national benchmark statistics.
Develops and maintains policy and procedure manuals for assigned staff. Reviews and updates policy and procedures, as well as specific desk procedures, as necessary.
Communicates with Clinical Services Management regarding pertinent issues in Patient Access, Front desk, Accounts Receivable in clinical areas.
Notifies program administration and staff of regulatory updates or changes in a timely manner.
Seeks, reviews, and recommends relevant software configuration updates and modifications as needed to further enhance existing processes.
Contracting: In order to be viable and sustainable, Clinics need to maintain a wide variety of competitive insurance contracts that reflect terms that meet the needs of the organization and support the triple aim. Therefore, the CCQ Specialist must maintain:
- Consistent management of all insurance proposals and contracts.
- oversight of the contract management process, as well as development of specific standards for review, analysis and submission of contracts
- collaboration with various departments, including clinical operations, financial, legal
- specific standards for submission, contract negotiations and document management.
- the highest principles of integrity and compliance.
- Contracts and proposals in organizational databases and securely maintained.
- Standards for contracts, including presentation of budget, payment terms, general language and provisions.
- appropriate clinical, administrative and operational research to support proposal and contract development.
- Contract strategy meetings to identify issues and client requirements, facilitate pricing discussions, and obtain senior management input on timelines and deliverables.
- Contractual provisions based on strategy discussions, senior management input, and organizational needs and expectations.
- Accuracy and appropriateness of contract text and attachments.
- Interface with insurance companies regarding adequacy of coverage
- Role as primary organizational contact during contract negotiations.
- Engagement with relevant stakeholders in negotiation decisions involving legal or regulatory requirements, contract standards and cost targets.
- Development and execution of negotiation strategies that minimize potential losses and benefit the organization’s financial performance.
- Deadlines on deliverables and communicate on an ongoing basis with all areas about contractual issues.
- Contractual performance metrics to ensure compliance with terms and to identify conflicts or changes requiring resolution at contract renewal.
Credentialing: Provider and insurance credentialing must be maintained in an
accurate and up to date manner in order to maintain regulatory compliance and quality assurance.
Therefore, the CCQ Specialist must:
- ensure providers are credentialed, appointed, and privileged with all health plans
- prepare and maintain reports of credentialing activities such as accreditation, membership or facility privileges.
- ensure that all information meets federal and state guidelines when processing applications.
- Maintain up-to-date data for each provider in credentialing databases and any online systems
- regularly complete and submit staff credentialing or re-credentialing applications to the appropriate agencies and track when certifications are due to expire.
- overseeing the auditing of a facility or individual practitioner.
- Review and verify all credentialing applications prior to submission to the Board of Directors and Credentialing source
- Maintains provider information in an online credentialing or other system.
- Track license and certification expirations for all providers to ensure timely renewals.
- Compiles and maintains current and accurate data for all providers.
- Completes provider credentialing and re-credentialing applications; monitors applications and follows-up as needed.
- In conjunction with Human resources :
- Maintain copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.
- Maintain corporate provider contract files.
- Maintain knowledge of current health plan and agency requirements for credentialing providers.
- Ensures practice addresses are current with health plans, agencies and other entities.
- Audits health plan directories for current and accurate provider information.
- Maintains confidentiality of provider information.
- Provides credentialing and privileging verifications.
Quality: In order to achieve optimal outcomes and regulatory compliance quality must be maintained and incorporated into all aspects of service delivery.
Therefore, the CCQ Specialist must
Serve as department liaison facilitating communication and collaboration with TRC QA/QI Department and all external partners related to QA
Ensure the completion of department audits to assess, verify and /or monitor compliance with agency and/or program policies and procedures.
assists in the annual revision of Department Policies and Procedures to comply with changes in regulations and/or improve departmental/program practices.
track, review, and analyze data relating to continuous quality improvement, and implement programmatic changes based on such data collection and analysis.
Gather and analyze data relevant to the continuous quality improvement
Review and make recommendations to program leadership based on data gathered and, or trends identified.
Review findings of internal audits with the Director(s) and AED, Corp. Compliance and applicable program staff and supervisors.
Assist with internal investigations and reviews as needed.
Attend Incident Review Committee and Compliance Committee meetings.
Other duties as assigned.
be service-aligned to build effective relationships with the interdisciplinary team and leadership to facilitate the integration of clinical quality indicators into the work environment and to actively promote a culture of patient safety, proactive risk management, and on-going regulatory readiness and compliance with standards of care.
Maintain a system for development, review and maintenance of program plans.
Support the Director in the development of annual Program Goals & Outcomes.
Assists with the development of plans for measuring and tracking outcome data.
Recommend improvements in evaluation questions, outcome measurement, analysis, presentation and utilization.
• Contributes to the development of and assists in the maintenance of all quality standards, including service provision and documentation; works with service providers to assure compliance to these standards taking into consideration agency and program needs,
• Collaborates with service providers on quality principles and value of meeting/exceeding quality standards; provides training to respective staff on establishing best practices.
• Coordinates Utilization Review processes;
• Analyzes, summarizes and reports on the results of the Utilization Review and prepare quarterly reports to address trends in findings
• Create action plans with program teams to address deficiencies found in the Utilization Review Quarterly report and monitor results over time to ensure improvements are made.
• Maintain strategy for obtaining customer feedback, including surveys, focus groups and interviews.
• Manages the administration of customer surveys, in collaboration with programs.
• Designs and conducts focus groups.
• Analyzes the results of customer feedback and reports results to the agency.
Badge access , multiple sites , various hours
Staff Training system
Multiple E HR’s
Timekeeping & Payroll
Various Insurance Portals
Internals / External E-mail
Internet Access – frequent use , sites
VPN access to systems
Shared drives – program areas
- Job Family TRC
- Pay Type Salary
- 880 E 2nd St, Jamestown, NY 14701, USA