Revenue Cycle Specialist

Summary:

The primary responsibility of this position is to identify and analyze circumstances that result in an open claim status. This involves coordinating tasks to guarantee that both external and internal deadlines are adhered to, facilitating the prompt processing and resolution of open claims. The objective is to conclusively settle all claims within the designated timely submission period. This encompasses but is not limited to, overseeing the coordination of billing procedures and conveying identified trends and patterns to relevant stakeholders while accurately applying contractual obligations and service level agreements during the execution of billing operations.

Duties & Responsibilities:

• Identifies and performs a root cause analysis for any systemic issues associated with adjudicated claims that may impact upstream billing to the health plans and provides follow-up with internal and external parties as applicable to address reasons for denial.

• Demonstrates knowledge of insurance regulations and policies, payment policies/guidelines, and the ability to communicate and work with payers to get claims resolved and paid accurately.

• Review payer 277/277CA and 835 responses and adjust the claim accordingly.

• Accurately and efficiently review patient demographic and insurance data in our proprietary billing system as it relates to covered services and areas.

• Files and tracks the progress of appeals and reconsiderations of claim decisions by assigned payer(s).

• Identifies and communicates trends and patterns that reflect deficiencies in the revenue cycle process that require multi-department collaboration and/or systematic development.

• Serve as the point of contact for all inquiries from health plans, while providing superior customer service and effectively communicating with insurance companies to ascertain claim status and specific claim dispositions.

• Maintain the strictest confidentiality; adhere to all HIPAA (Health Insurance Portability and Accountability) and other industry rules and regulations.

Requirements:

• College education in health services administration, accounting, business, or similar discipline or equivalent experience.

• Knowledge of medical billing and coding.

• Certified Coding Specialist (CCS)/Certified Coder Associate (CCA)/AAPC - CPC Certified

• Professional Coder desirable.

• Minimum of 1 year experience in end-to-end revenue cycle management.

• Experience with clearinghouse platforms and RCM systems, preferably Waystar, Optum, and Availity.

• Experience working independently and as a member of various teams and/or workgroups.

• Strong computer skills and knowledge of MS Office products with intermediate Excel level

• Ability to quickly navigate between different system platforms.

• Strong written and verbal communication skills.

• Strong organizational skills, problem-solving, and analytical skills.

• Acute attention to detail.

• Bilingual (English/Spanish) is desirable.