AR Specialist

About the role

The Revenue Cycle Specialist is a hands-on, cross-functional operator capable of working directly within client EHR and billing systems to execute the full lifecycle of a claim from eligibility verification and demographic accuracy through direct claim submission, edit resolution, and AR follow-up to final account resolution.

Job Responsibilities

• Flex across assigned functional areas (eligibility, demographics, billing, edit resolution, AR follow-up, and denial management) based on client volume, priority, and engagement need
• Verify active insurance coverage and benefits using payer portals, EDI 270/271 transactions, and direct payer outreach; document coverage details including effective dates, plan type, network status, copays, deductibles, coinsurance, and benefit limitations
• Determine primary, secondary, and tertiary payer order in accordance with coordination of benefits rules; identify Medicare Secondary Payer, workers' compensation, motor vehicle accident, and third-party liability scenarios
• Flag services requiring prior authorization, pre-certification, or referral and route to the appropriate team
• Review, correct, and validate patient demographic, guarantor, subscriber, and insurance plan data in the EHR, PMS, or registration system; resolve demographic-related rejections and registration errors at the root
• Submit clean claims directly to payers via Medicare DDE/FISS, state Medicaid portals, and payer-specific direct submission channels, working natively in client EHR and billing systems rather than exclusively via clearinghouse
• Resolve front-end claim edits, scrubber rejections, and pre-submission errors at the source system level, including demographic, eligibility, payer ID, modifier, diagnosis, and revenue code corrections
• Interpret and resolve NCCI procedure-to-procedure edits, MUE edits, LCD/NCD policy edits, and bundling logic
• Correct UB-04 and CMS-1500 field-level data including revenue codes, HCPCS, occurrence/conditions/value codes, modifiers, place of service, and rendering provider information as applicable
• Work aged accounts receivable, prioritizing high-dollar and high-aging balances to maximize cash collections
• Contact payers via phone, portal, and electronic inquiry to determine claim status, identify denial or pending reasons, and drive claims toward payment
• Research and resolve claim denials and underpayments by identifying root causes and taking corrective action (rebilling, reconsiderations, appeals, corrected claims, medical records submission)
• Prepare and submit written appeals with supporting clinical documentation, operative reports, and payer policy references
• Identify and pursue underpayments by comparing actual reimbursement against expected contract terms
• Manage payer follow-up across all payer classes including Medicare (Traditional and Advantage), Medicaid, commercial, managed care, workers' compensation, TRICARE, and VA
• Analyze rejection and denial trends to identify systemic issues and escalate with data-driven recommendations to leadership
• Collaborate with coding, charge capture, patient access, HIM, and client-side teams too resolve upstream issues impacting claim payment
• Document all account activity with clear, concise, and actionable notes in the source system
• Maintain productivity and quality standards in a high-volume, deadline-driven, metrics-oriented environment
• Maintain full compliance with HIPAA, payer guidelines, CMS regulations, and federal/state billing regulations at all times

Requirements

• A High School Diploma or GED
• CRCR (Certified Revenue Cycle Representative) or CRCS (Certified Revenue Cycle Specialist) certification preferred
• 3-5 years of hospital and/or physician revenue cycle experience in at least two of the following: eligibility/benefits verification, demographic/registration data integrity, billing and claim edit resolution, AR follow-up, and denial management
• 6+ years of cross-functional hospital revenue cycle experience covering all five focal areas (eligibility, demographics, billing, rejections/edits, AR follow-up) preferred
• Hands-on experience submitting claims directly to payers via Medicare DDE/FISS, state Medicaid portals, and/or payer-specific direct submission channels, not exclusively via clearinghouse
• Experience with Medicare FISS/DDE direct submission and adjustment workflows preferred
• Familiarity with both facility (UB-04) and professional (CMS-1500) claim types preferred
• Experience with credit balance resolution, underpayment recovery, or contract variance analysis preferred
• Prior experience in a healthcare outsourcing or multi-client environment with client-specific SLA and productivity targets preferred
• Comprehensive knowledge of UB-04 and CMS-1500 claim forms, revenue codes, CPT/HCPCS, ICD-10-CM, and modifier usage
• Expertise in major payer processes including Medicare, Medicaid, TRICARE, VA, and commercial payers
• Working knowledge of NCCI edits, MUE edits, LCD/NCD policy logic, and bundling rules
• Hands-on experience with major payer portals (Availity, NaviNet, UHC, Aetna, Cigna, Anthem, Medicare MAC portals, state Medicaid portals) and EDI 270/271 eligibility transactions
• Knowledge of coordination of benefits, primary/secondary/tertiary payer determination, and Medicare Secondary Payer rules
• Strong analytical skills to interpret EOBs, remittance advices, contracts, and payment documentation
• Solid Excel skills (filtering, sorting, pivot tables, basic formulas) and comfort working across multiple systems simultaneously

Qualifications

• Ability to establish and maintain effective working relationships with team members, supervisors, managers, clients, and providers
• Ability to prioritize workload and manage multiple responsibilities in a highly organized, efficient, and effective manner
• Knowledge of HIPAA, billing compliance, CMS regulations, and fraud/abuse regulations

Skills

• Bilingual (English/Spanish) for patient-facing communication preferred

Benefits

Access to a 401(k) Retirement Savings Plan.
Comprehensive Medical, Dental, and Vision Coverage.
Paid Time Off.
Paid Holidays.
Additional benefits, including Pet Care Coverage, Employee Assistance Program (EAP), and discounted services.