JOB SUMMARY: The Revenue Cycle Specialist II must adhere to the Code of Ethical Conduct and foster positive relationships within the company, across departments, and with external stakeholders. This role involves billing and follow-up of accounts according to documented procedures. Responsibilities include following up on claim status, billing and re-billing of claims, credit balance resolution, denial management, following up on aging accounts, maintaining up-to-date account information, submitting written appeal letters, engaging in extensive telephone contact with insurance companies, using contract summaries to verify balances due on disputed claims, and coordinating payor denial and appeal follow-up activities. This also involves ensuring timely response from third-party payors, processing payor denials, documentation requests, and appeals, and monitoring day-to-day activities related to appeal follow-up and denials. Additionally, the Specialist is responsible for understanding and complying with the rules and regulations of state and federal regulatory agencies and other certified agencies.   MAJOR RESPONSIBILITIES/ACTIVITIES: The responsibilities of the Revenue Cycle Specialist I can be organized and clarified into distinct categories: Claims Processing and Revenue Generation: + Collect outstanding claims. + Run pre-billing reports and claims for review. + Review, transmit, and/or mail claims. + Ensure filing of accurate claims according to payer specifications. + Submit claims corrections or adjustments as needed. + Document required backup/approvals for revenue adjustments/changes. + Assemble required backup/approvals for revenue resulting in bad debt. + Work with other departments to ensure accurate billing information. + Generate unbilled revenue reports and confirm all patients are accounted for. + Work unbilled revenue report weekly by communicating missing information to other departments. Regulatory Compliance and Knowledge Management: + Maintain up-to-date knowledge of Insurance Contracts and notify the Revenue Cycle Manager of any problems or deviations. + Maintain up-to-date knowledge of Medicare, Medicaid, and Private Insurance rules/procedures/rates for billing. + Monitor every outstanding claim on the aging report at least once every two weeks. + Investigate and document every follow-up attempt for accounts over 60 days old. + Monitor Medicaid and Private Insurances websites, clearinghouses, and Remittance Advice (RA)/Explanation of Benefits (EOBs) daily to ensure claims processing. Financial Management: + Post deposits daily or weekly as needed. + Balance EOB/RA’s to deposit entry and bank printouts. + Provide refund information to the accounting department for accounts payable processing. + Assist with the preparation and delivery of items required for annual audits. Denials Management and Accounts Receivable Follow-Up: + Manage and resolve A/R claims over 60 days old. + Follows up on claim rejections and denials to ensure appropriate reimbursement for our clients. + Process assigned AR work lists provided by the manager in a timely manner. + Write appeals using established guidelines to resolve claim denials with a goal of one contact resolution. + Identified and resolved denied, non-paid, and/or non-adjudicated claims and billing issues due to coverage issues, medical record requests, and authorizations. + Recommend accounts to be written off on Adjustment Request + Reports address and/or filing rule changes to the manager. + Check system for missing payments. + Properly notates patient accounts. + Review each piece of correspondence to determine specific problems. + Research patient accounts + Reviews accounts and determines appropriate follow-up actions (adjustments, letters, phone insurance, etc.) + Processes and follows up on appeals. Files appeals on claim denials. + Scan correspondence and index to the proper account + Inbound/outbound calls may be required for follow up on accounts. + Route client calls to the appropriate RCM + Respond to insurance company claim inquiries. + Communicates with insurance companies for status on outstanding claims. Credentialing: Provide backup support for Revenue Cycle: + Credential all new providers and ensure current providers are up to date with all insurance plans. + Maintain individual provider files for credentialing applications. + Update and maintain accurate information for all providers in credentialing software and folders. + Maintain Providers CAQH profiles and credentialing database. + Assist with business licenses, renewals, liability policies, and payer contracts. + Provide weekly statuses of provider progress to management. + Work closely with Revenue Cycle Manager and billing staff to identify and resolve issues related to provider credentialing. OTHER RESPONSIBILITIES/ACTIVITIES + Manage workflow to ensure timely submission of requests, returned documents, and deadlines are met. + Communicate effectively with the team and maintain confidentiality. + Self-organize work assignments for efficiency. + Completion and/or involvement in special projects. + Participation in relevant meetings, trainings and/or company-sponsored events. EDUCATION & EXPERIENCE: + Minimum of two (2) years of billing/ collections experience in a healthcare or insurance environment. + Experience with and knowledge of FQHCs billing (Federally Qualified Health Centers). SUPERVISORY RESPONSIBILITIES: + N/A QUALIFICATIONS: + Knowledge of accounting; math skills. + Basic knowledge of Medical and Billing Terminology. + Basic knowledge related to electronic claims submissions and remittance procedures. + Experience working with practice management software. + Knowledge of healthcare carriers and payer requirements. + Knowledge of Medicare, Medicaid, compliance, insurance, liability and tertiary payment methods + Intermediate knowledge of Excel and Windows-based programs. + To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements contained within this document are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential  functions. PERFORMANCE REQUIREMENTS: + Ensure that company policies and state, federal, and HIPAA regulations are followed. + Adhere to the company’s timekeeping and attendance policy on a daily basis. + Work at the established productivity levels with accuracy and timeliness. + Show independence in working efficiently and gaining necessary knowledge with minimal assistance. + Demonstrate dependability. + Advocate for our patients/clients by continually improving our team's operational, clinical, and financial processes and resolving issues. + Interact and collaborate with various positions internally and externally to find the best solutions. + Build consultative client relationships, work well with internal partners, and thrive in a dynamic, team-focused environment with tight deadlines. + Participate in cross-training and job enlargement opportunities. + Contribute ideas for improving Revenue Cycle processes. + Adapt to learning new processes, concepts, and skills. + Help orient and train team members. + Maintain positive work relationships with team members. SKILLS & ABILITIES: + Strong organizational, quantitative skills and analytical skills. + Demonstrated accuracy with a strong attention to detail. + Excellent work ethic and ability to prioritize tasks. + Detailed and process improvement oriented. + Excellent problem-solving skills. + Ability to present findings and discuss issues with providers effectively. + Ability to work independently and as a part of a team in a deliverable-focused professional environment. + Ability to shift focus as necessary when priorities change without losing sight of original assignments. + Willing and able to work extended hours as business needs require. + Strong sense of confidentiality and professionalism regarding company and employee information. + Strong problem-solving and analytical skills that demonstrate resourcefulness and initiative. + Strong listening, decision-making, time management, communication, and critical-thinking skills. + Performance-driven with demonstrated ability to multi-task and work proactively with cross-functional teams. + Proficiency with Microsoft Office programs particularly excel. REQUIRED CERTIFICATIONS AND LICENSURES: + N/A PREFERRED EDUCATION, CERTIFICATIONS & EXPERIENCE: + Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS), Certified Professional Coder-Payer (CPC-P) or Certified Professional Coder-Payer (CPC-P). LANGUAGE SKILLS: + Ability to read, write, speak and comprehend written documents fluently. MATHEMATICAL SKILLS: + Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations. REASONING ABILITY: + Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables. WORK ENVIRONMENT: + This job operates in a healthcare setting. This position requires frequent standing and walking. + The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation will be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. + This job description includes the major duties and responsibilities of the job but is not inclusive of every task inherent to the job. In addition, it may be occasionally necessary for employees to be assigned tasks not specifically covered by their permanent assignment. Employees will be expected to comply with reasonable requests from their supervisor. PHYSICAL DEMANDS: + Most of the time is spent in a normal office environment. + Possession of motor skills required for use of computer keyboard, telephone, various office equipment and filing of paperwork. + Flexibility to work extended hours to support the business as required. + Occasional travel required, sometimes on short notice. + PHC will comply with the Americans with Disabilities Act, including the Americans with Disabilities Act Amendment Act, and all other Federal, State, and local legislative requirements. PHC will ensure that reasonable accommodations are made to enable a qualified individual with a disability to perform the essential functions of that position. COMPETENCIES ESSENTIAL FOR SUCCESS: + Ethics/Company Values + Communication + Developing/Coaching Others + Maturity/Judgment + Intellectual Capacity + Technical/Business Knowledge + Planning/Organization     Powered by JazzHR