Revenue Cycle Specialist

About the role

The Revenue Cycle Specialist is responsible for managing and resolving outstanding claims and ensuring all accounts are worked systematically within prescribed timeframes. The AR Representative must adhere to a structured weekly workflow, optimizing claim trends and addressing high-dollar, oldest, and small-dollar accounts. Correspondence, medical records submission, and appeals must be completed by the end of each week to maintain compliance and minimize delays.

Weekly Workflow

• Monday: Analyze and optimize account trends, identifying opportunities for resolution and improvements in workflows.
• Tuesday: Focus on and resolve all high-dollar accounts ($5,000), ensuring timely follow-up and documentation.
• Wednesday: Address the oldest claims in the system, prioritizing based on aging and financial impact.
• Thursday: Work on small-dollar accounts ($5,000), ensuring all minor balances are cleared and reconciled.
• Friday: Complete all pending correspondence and ensure necessary documentation is submitted to payers. Submit medical records for any claims requiring additional support. Work on miscellaneous accounts that do not fall into specific categories, ensuring no claims are overlooked. Finalize and send out all appeals for the week, ensuring they are submitted via certified mail for tracking and compliance purposes.

Responsibilities

• Work claims within 5 business days of submission to ensure timely resolution.
• Prioritize and process high-dollar claims ($5,000) within 5 business days to reduce financial risk.
• Conduct follow-ups with payers to resolve denials, rejections, and payment delays.
• Monitor and escalate unresolved claims as appropriate to ensure compliance with payer and organizational standards.
• Document all claim activities and payer interactions accurately and comprehensively in the system.
• Maintain detailed records of high-dollar claims, appeals, and correspondence to ensure accountability.
• Provide regular updates to supervisors on claim status, trends, and unresolved issues.
• Ensure all claims are worked in compliance with federal, state, and payer regulations.
• Follow organizational policies and procedures for timely appeals and resubmissions.
• Participate in audits and quality checks to identify and resolve errors in claim management.
• Work closely with other revenue cycle team members to address barriers to claim resolution.
• Communicate with payers to resolve discrepancies, delays, and denials effectively.
• Escalate unresolved or complex cases to the AR Supervisor/Manager as necessary.
• Identify delinquent accounts, aging period and payment sources by contacting third party payers.
• Research insurance credit balances and regularly write up requests for refunds.
• Appeal incorrectly processed claims, and if necessary, make the appropriate adjustment.
• Refile primary paper claims & secondary claims within a timely manner.
• Assist secretaries and patients with insurance issues and questions.
• Handle incoming correspondence from insurance companies.
• Scan documents when necessary, into the practice management system.
• Negotiate payments with non-contracted insurance payers.
• Attend specific insurance training seminars/webinars as required.
• Participate in appeals hearings as requested by specific insurance companies.
• Maintain privacy, confidentiality, and security of patient, client, staff, and organizational data.
• Post office and ancillary procedure charges to computer system.
• Balance charge totals when batch is completed.
• Contact physician's immediate staff for corrections needed in order to process the charge. If not received in a timely manner, follow up with them again until all corrected information is received.
• Keep supervisor informed of any recurring problems regarding charge batches.
• Follow up on all holds and ensure all tickets put in the status of hold are cleared out within 45 days, and if not, bring this to the attention of the Revenue Cycle Director.
• Ensure all tickets that are in a status approved failed due to lacking demographic information are fixed within a timely manner.
• Ensure all information is entered on account so that a clean claim will go out.
• Work with patients to obtain payment for services and provide alternative payment plans to resolve outstanding debt.
• Answer main business office telephone lines and process calls.
• Accurately update financial and demographic information into the appropriate system.
• Interact with collection agencies, bankruptcy and deceased patient accounts as required.
• Process patient receipts per BBS standards.
• Identify and process patient refunds as needed.

Qualifications

• High school diploma or G.E.D required.
• Two years prior experience in a private practice or hospital billing/business office preferred.
• Insurance billing experience utilizing CPT, ICD-10 and modifier coding preferred.

Skills & Performance Requirements

• Demonstrates acute awareness of insurance company contracts.
• Displays ability to analyze payment denials and compose letters of appeal.
• Possess ability and desire for cross training in all areas of the Business Office.
• Reports to work regularly without undue tardiness.
• Maintains positive attitude and demonstrates the utmost in professionalism.
• Dresses appropriately and professionally.
• Works independently, without supervision, completes work accurately and in a timely manner.
• Maintains effective working relationships with physicians, administration and other staff members.
• Demonstrates good communication skills with other staff members as well as patients, insurance companies, outside physician offices, and physicians.
• Possesses ability to identify areas of account problems and explain effectively to patients.
• Attends staff meetings and participates in special committees as required.
• Other duties and assignments as necessary, overtime as required.