Job Description

The Revenue Cycle Specialist is responsible for responding to and resolving a variety of account, billing and payment issues from patients and insurance companies. Reviews the medical record and abstracted information as necessary to provide insurance claim information or to resolve incoming correspondence regarding patient services. Reviews accounts to determine correct adjustments have been applied, payments posted and refunds distributed. Uses excellent customer service and interpersonal skills when interacting with patients and insurance companies, following confidentiality guidelines. Makes appropriate decisions that require individual and/or team analysis – utilizing good problem-solving skills. Interprets, applies and communicates federal regulations, insurance contracts and hospital-wide policies regarding the medical and financial aspects of patient care to ensure optimal third-party payment for the patient and the hospital.

Responsibilities/Duties:

• Upload daily claim files to electronic claim software.
• Process complete and accurate claims in a timely and efficient manner, assuring that the payer guidelines are followed, facilitating compliance and maximum reimbursement.
• Resolve system billing and claim WQ edits by working closely with Clinical departments, coding staff and registration to assure errors are completed correctly and in a timely manner.
• Takes a team approach to communicating insurance updates/changes to other specialist as well as external departments to assure compliance with all changes.
• Utilize follow-up/denial WQ and Aging reports to assure all unprocessed claims and denials are followed up on timely. Utilize problem solving/root cause analysis to help identify possible solutions and work closely with your manager to update systems as needed.
• Accurately submit claim appeals to support our charges and reason for appealing.
• Utilize system tools and available department resources to achieve efficiency and timely resolution of patient accounts. Consistent use of online payer resources.
• Investigates and responds to insurance correspondence, questions and/or request for additional information in a timely and professional manner to ensure proper, timely and accurate payment of patient accounts.
• Review and process insurance and patient overpayment. Identify large insurance adjustments and review contract to identify underpayments.
• Assist with the preparation of the Medicare Quarterly credit report and Medicare bad debt report.
• Serves as back up customer service. Accepting patient payments and setting up payment plans.
• Performs other duties as required.
• Adheres to STAR Standards policy.

Education/Experience:

• High School diploma or equivalent preferred
• Completion of Medicare Certification program for a part A and Part B within 1 year of hire.
• One-year experience in healthcare, with knowledge of medical terminology preferred.
• AAHAM certified Revenue Cycle Specialist (CRCS) preferred.