Revenue Cycle Specialist I - Priority Health Care

JOB SUMMARY:

As the Revenue Cycle Specialist, I must adhere to the Code of Ethical Conduct and foster positive relationships within the company, across departments, and with external stakeholders. The primary responsibilities include generating accounts receivable revenue, processing claims, following up on claims, maintaining collection notes, posting deposits, submitting provider notifications, and balancing all aspects of accounts receivable. Additionally, the Specialist is responsible for understanding and complying with the rules and regulations of state and federal regulatory agencies and other certified agencies. Credentialing new and current providers with Insurance Plans are also part of the role's responsibilities.
 

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.

Credentialing:

• 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.

Insurance Verification and Authorization:

Provide backup support for Patient Services Specialists

• Complete insurance verification and follow up for authorizations.
• Contact insurance carriers for benefit coverage details.
• Ensure accurate information application and review within timelines.
• Enter data accurately into the software program.
• Scan and upload documents, support authorization/verification.
• Document payer and authorization details in the EMR system.
• Maintain payor portals and handle notifications of changes.

• Complete insurance verification and follow up for authorizations.
• Contact insurance carriers for benefit coverage details.
• Ensure accurate information application and review within timelines.
• Enter data accurately into the software program.
• Scan and upload documents, support authorization/verification.
• Document payer and authorization details in the EMR system.
• Maintain payor portals and handle notifications of changes.
• Verify policy benefits, educate patients on insurance, and notify departments accordingly.

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

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