Contract Utilization Review Jobs in Rio Rancho, NM

Position Summary
The Business Office Manager is responsible for the overall daily operations and financial stewardship of the Health Center Business Office, including revenue cycle management, accounts receivable, third-party payer contract management, patient registration, scheduling, and other business office functions.
The position oversees the Tribal Member Health Insurance Program and supports business office functions related to Purchased Referred Care (PRC). Responsibilities include monitoring insurance eligibility and coverage, coordinating payer requirements, supporting appropriate patient financial processes, and working collaboratively with clinical and administrative departments to maximize available third-party resources.
The Business Office Manager is also responsible for provider credentialing and enrollment for insurance billing, accreditation, and other applicable requirements. Responsibilities include coordinating initial credentialing, recredentialing, payer enrollment, licensure and certification tracking, and maintaining complete and current provider records to support uninterrupted patient care, billing, reimbursement, and regulatory compliance.
The position monitors key financial and revenue cycle performance indicators, identifies trends and opportunities for improvement, develops and implements corrective actions, and provides regular financial and operational reporting to Health Center leadership. The Business Office Manager works collaboratively with providers, clinical leadership, finance, information technology, third-party payers, and other departments to ensure efficient operations, regulatory compliance, financial accountability, and the overall effective management of the Health Center Business Office.
Our philosophy is built on the principles of integrity, fairness, collaboration, communication, and recognition for performance excellence. Meeting all performance standards leads to attracting and retaining a qualified workforce, provides opportunities for qualified team members, and contributes towards the ongoing success of the Pueblo of Sandia today and in the future.
Essential Duties and Responsibilities

1. Provide leadership, direction, supervision, training, and performance management for Business Office staff, including personnel responsible for billing, coding, patient registration, scheduling, accounts receivable, insurance, PRC,and related functions.
2. Oversee the complete revenue cycle to ensure timely and accurate charge capture, coding, claim submission, payment posting, denial management, follow-up, collections, and resolution of outstanding accounts.
3. Monitor accounts receivable aging, denial trends, reimbursement patterns, clean claim rates, collection performance, and other key revenue cycle indicators; develop and implement corrective action plans as needed.
4. Ensure billing and coding practices comply with applicable federal and state regulations, payer requirements, coding guidelines, organizational policies, and other applicable compliance standards.
5. Review and monitor third-party payer contracts, reimbursement rates, payer requirements, and operational impacts; work with leadership and payers to identify and resolve reimbursement or contract-related issues.
6. Oversee patient registration and scheduling processes to ensure accurate demographic, insurance, eligibility, and other required information is collected and maintained.
7. Oversee the Tribal Member Health Insurance Program, including processes related to eligibility, enrollment, coverage verification, utilization of available benefits, and coordination with staff and third-party payers.
8. Support and coordinate Business Office functions associated with Purchased/Referred Care (PRC), including verification of coverage, coordination of benefits, documentation, billing-related processes, and maximization of available third-party resources.
9. Serve as the Health Center's HIM lead and provide oversight of health information management practices, including record integrity, release and disclosure of information, retention, confidentiality, and appropriate access to health information.
10. Coordinate provider credentialing, recredentialing, payer enrollment, and accreditation-related requirements to ensure providers maintain appropriate credentials and remain eligible for insurance billing and participation.
11. Maintain accurate and current provider files, including licensure, certifications, professional liability coverage, education, training, credentialing, enrollment, and other required documentation.
12. Develop, implement, and maintain Business Office policies, procedures, internal controls, workflows, and standard operating practices to promote efficiency, accountability, compliance, and financial sustainability.
13. Prepare and present regular financial, revenue cycle, operational, and performance reports to Health Center leadership and make recommendations for process improvement.
14. Participate in budget development, financial planning, forecasting, and monitoring of Business Office operations and revenue-related activities.
15. Collaborate with clinical leadership, providers, finance, information technology, compliance, PRC, and other departments to resolve operational issues and improve patient access, reimbursement, data integrity, and overall service delivery.
16. Respond to and assist with internal and external audits, accreditation reviews, compliance monitoring, payer audits, and other regulatory or financial reviews.
17. Protect the confidentiality and security of patient, employee, provider, financial, and organizational information in accordance with HIPAA and applicable laws, regulations, and organizational policies.
18. Maintain current knowledge of healthcare billing, coding, reimbursement, credentialing, privacy, health information management, and applicable regulatory requirements.
19. Perform other related duties as assigned to support the efficient operation and financial stewardship of the Health Center.
20. Duties as assigned by Health Director: Completes any and all assigned duties; other than those listed above, by Health Center Director in a documented and timely manner based on directions, timelines and departmental goals.
21. Punctual and regular attendance is an essential responsibility for all team members and are expected to report to work based upon the assigned schedule each day in accordance with the Attendance Policy for Pueblo of Sandia.

Additional Responsibilities

1. Will be assigned committee work as appropriate for AAAHC accreditation.
2. RPMs package owner as appropriate for the position; works with the CAC and the other Health Center managers to ensure capture of data for program measurements and billing.

Key Performance Indicators
This position has Key Performance Indicators (KPI's) identified as a measurement of success. KPI's will be shared with all team members who work in this job title and feedback will be provided regarding the successful completion of the KPI's as part of the performance review process.
Knowledge, Skills, and Abilities

1. Detailed knowledge of rules, procedures, and operations related to alternate health resources
2. Knowledge of PL 93-638 the Indian Health Care Improvement Act and Purchased Referred Care (Contract Health Services).
3. Knowledge of principles and policies of fiscal, accounting, budgeting and statistical analysis
4. Knowledge of third party and alternate resources, such as AFDC, SSI, Medicaid, Medicare, private insurance, etc.
5. Experience with standardized data processing rules, specialized coding and medical terminology.
6. Knowledge of rules of confidentiality and applicable guidelines.

Education and Experience
Required:

1. High School Diploma, GED certification or equivalent
2. Bachelor's degree from an accredited college or university
3. Three (3) years' experience with business operations and software.

Note: Any combination of education from an accredited college or university in a related field and/or direct experience in this occupation totaling eight (8) years may substitute for the required education and experience.
License/Certifications/Registrations

1. Must be able to successfully pass a stringent background investigation and character investigation in compliance with PL 101.630.
2. Will require a pre-employment and random drug screening.

Physical Requirements/Working Conditions
The following selected physical activities are required to perform the essential functions of this position
Physical Requirement
Description
Balancing
Maintaining body equilibrium to prevent falling and walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
Crouching
Bending the body downward and forward by bending leg and spine.
Feeling
Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.
Finger Dexterity
Picking, pinching, typing or otherwise working, primarily with fingers rather than with the whole hand as in handling.
Grasping
Applying pressure to an object with the fingers and palm.
Hearing
Perceiving the nature of sounds at normal speaking levels with or without correction. Ability to receive detailed information through oral communication, and to make the discriminations in sound.
Kneeling
Bending legs at knee to come to a rest on knee or knees.
Lifting
Raising objects from a lower to a higher position or moving objects horizontally from position-to-position. This factor is important if it occurs to a considerable degree and requires substantial use of upper extremities and back muscles. (Up to 10 lbs.)
Pulling
Using upper extremities to exert force to draw, haul, or tug objects in a sustained motion. (Up to 10 lbs.)
Pushing
Using upper extremities to press against something with steady force to thrust forward, downward, or outward. (Up to 10 lbs.)
Reaching
Extending hand(s) and arm(s) in any direction.
Seeing
The ability to perceive the nature of objects by the eye.
Walking
Job requirements include, in the performance of duties, walking throughout the work area, on various work surfaces throughout internal or external locations.
Sitting
Particularly for sustained periods of time.
Standing
Particularly for sustained periods of time.
Stooping
Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full motion of the lower extremities and back muscles.
Talking
Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
List Working Conditions Required:

1. Work is performed indoors.
2. May work extended hours and evening or weekend hours.
3. Subject to hazardous materials which may cause bodily harm: smoke, common colds, influenza, dust, odors and elevated noise levels.
4. Tasks may be performed on uneven, inclined, challenging, soft carpeted floors, cement structures, and surfaces.