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Overview

Tri-City Medical Center has served San Diego County’s coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region for more than 60 years and is one of the largest employers in North San Diego County. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District. As a full-service acute care public hospital with over 500 physicians practicing in over 60 specialties, Tri-City is vital to the well-being of our community and serves as a healthcare safety net for many of our citizens. The hospital has received a Gold Seal of Approval® from the Joint Commission showcasing a commitment to safe and effective patient care for the residents of the community. 

Tri-City Medical Center prides itself on being the home to leading orthopedic, spine and cardiovascular health services while also specializing in world-class robotic surgery, cancer and emergency care. Tri-City’s Emergency Department is there for your loved ones in their time of need and is highly regarded for our heart attack and stroke treatment programs. When minutes matter Tri-City is your source for quality compassionate care close to home. Tri-City partners with over 90 local non-profit and community organizations as part of our COASTAL Commitment initiative. Together we are helping tackle some of our communities’ pressing health and social needs.

Position Summary:

This position reports directly to the Patient Accounting Supervisor and is responsible for working to resolve pre-billing edits which prevent clean claim submission. This position will work to identify root cause and work closely with Management across multiple departments to mitigate reoccurrence.

Major Position Responsibilities:

The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.

• Maintains a safe, clean working environment, including unit based safety and infection control requirements.
• Access multiple reports daily to identify encounters hitting delinquent data and/or placed on hold for research by a collector and/or member of management within the department.
• Pre-Billing
• Work all encounters hitting an APC/OCE edit daily by performing the necessary research, applying the correct modifier, adding/removing a charge if necessary and/or following-up with the department for assistance if required.
• Review accounts pending Modifier review by accessing Craneware and determining the necessity of the requested modifier and/or review the exception to determine if a charge could possibly be missing creating the issue.
• Review “LWOT” encounters in Cerner to determine if the patient was seen by a Physician’s Assistant and/or Physician while in Triage to determine the appropriateness of billing the encounter.
• Research MUE edits to determine if the code hitting the edit is packaged with a maximum quantity allowed, crediting any overage.
• Retrieve and email all encounters requiring review by Key Healthcare for OPOBS charging daily.
• Retrieve Missing ED Charge report monthly and determine if there is a missing emergency room charge and/or a missing procedure code. Work with KHC and/or HIM to determine next steps.
• Re-abstract encounters daily that have been placed on hold to ensure the appropriate APC/DRG/APR-DRG is reflected on the encounter.
• Identify encounters in which Invega is administered and coordinate charging with the Pharmacy prior to the bill dropping.
• Updating/Reabstracting encounters to provide Self-pay rates as needed.
• Other assigned duties pertaining to pre-billing edits, charge capture and AR as required.
• Work closely with IT to ensure 3M updates are current and factors correct.
• Cross Function
• Works in collaboration with the collectors and/or billers to review any encounters with an edit/denial that may have an issue outlined above.
• May assist in patient calls as well as place follow-up calls to insurance carriers.
• Training of new hires as necessary to ensure an understanding.
• Practice Requirements
• Ensures that patient confidentiality is always protected, both audible and visible
• Ensures compliance with all medical practice regulations, such as, but not limited to HIPAA and OSHA.

Qualifications:

• Minimum two (2) years’ experience in the performance of charge quality assessment in an acute care hospital, required.
• Proficiency in Microsoft Office, including Word, Outlook and Excel, required.
• Excellent interpersonal skills, including written and oral communication, required.
• Ability to work independently with strong attention to detail, required.
• Understanding of computer systems and their capabilities pertaining to coding, billing and grouper software, required.
• Knowledge of compliance concerns relative to coding, billing, reimbursement and documentation, required.
• Knowledge of CPT codes and modifiers, charge capture, communication changes in APC’s that may impact charging practices, required.
• Knowledge of APC structure, UB claim forms and hospital outpatient billing structure, required.
• Must be able to read and write in English.
• Must have ability to demonstrate flexibility and prioritize work load.

Education:

• High School diploma or GED, required.
• Associates or Bachelor’s degree, preferred.

Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work. 

*Salary/Hourly wage range for this position is posted. Actual pay will be determined based on verified experience as well as internal equity.

TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.