Revenue Cycle Specialist

About the role

The Revenue Cycle Specialist is responsible for the timely processing and follow-up on claims submitted to insurance companies and other entities for payment. Analyzes and reviews insurance claims for accuracy, completeness, and eligibility. Reviews claims for eligibility to be reimbursed. Maintains updated records and prepares required documentation. Assists in controlling the cost of processing claims. Contacts policyholders about claims and may provide information regarding the amount of benefits. Additionally, this position performs more in-depth review of claims to determine appropriate actions to recover claim payments and provides leadership and ongoing guidance to other team members assigned to the same or similar projects.

Responsibilities

• Read, evaluate, and appropriately analyze Explanation of Benefits (EOB) for accuracy and determination of appropriate follow-up actions with insurance companies.
• Analyze dental records and other applicable information to determine the appropriate appeal process.
• Review and prepare claims for electronic and hard copy billing submission.
• Provide research and root cause analysis for claim remediation.
• Standard documentation in the dental billing system for tracking processes and follow-up needed.
• Use pertinent data and facts to identify and solve a range of problems within area of expertise.
• Submit dental and medical claims to insurance companies on a timely basis.
• Identify and correct billing errors and resubmit claims to insurance carriers.
• Provide review and remittance advice for payment errors, denials, and underpayments.
• Follow up on unpaid claims within standard billing cycle time frames.
• Call insurance companies regarding payments, denials, and to check on EOBs.
• Identify and bill secondary or tertiary insurances.
• Answer all patient or insurance company telephone inquiries pertaining to assigned accounts.
• Research and follow up on client questions regarding statements and patient balances.
• Update the billing system with changes to insurance information and notes regarding progress, as well as alerts for Operations staff to collect on co-pay, etc.
• Research the accuracy of patient balances, resolve outstanding claims, ensure patients receive appropriate correspondence regarding their accounts, make patient calls for balances above certain thresholds, and turn over accounts to collection agencies with appropriate documentation.
• Review collection agency invoices for accuracy and correct office assignment, monitor collection folders for direct pays, and correct account addresses based on USPS files.
• Review adjustment reports requiring intimate knowledge of claim filing and claim payment tabs.
• Detect payer and provider trends indicative of underlying coverage issues and payer issues.
• Detailed understanding of how insurance coverages are set up, including procedures and category tabs, and how to adjust coverages as needed.
• Analyze the appropriateness of discount code write-offs.
• Identify provider credentialing issues and work with EDI Support and/or credentialing team to address and correct.
• Identify areas of revenue leakage and revenue opportunities, and propose improvements or operational enhancements to address.
• Perform other duties as assigned.

Requirements

• Bachelor’s degree or equivalent experience preferred.
• Prior supervisory or training experience preferred.
• Minimum of 5 years of experience in specialty insurance billing or collections required, including submitting and following up on claims.
• Experience in Dental, Hospital, or Physician Billing and Collections preferred.
• Proficiency with MS Office and Excel.
• Knowledge of a variety of hospital, physician, and/or dental billing systems required.
• Knowledge of a variety of insurance online systems as well as online status/eligibility inquiry sites required.
• Knowledge of general insurance guidelines a plus.

Skills

• Excellent analytical skills, solutions-oriented.
• Ability to handle sensitive material confidentially.
• Strong written and verbal communication skills.
• Ability to work independently and multi-task, understanding multiple products and levels of benefits within each project.
• Ability to communicate with leadership regarding complex insurance issues, using influence to reach desired outcomes.
• Solid understanding of how to reallocate payments to procedures.
• Identify, manage, and correct complex process issues.
• Builds constructive and effective relationships and establishes credibility; gains the trust of others through open communication and honest, constructive feedback.
• Puts the needs of the organization first and acts with the customer in mind.
• Relates well to people at all levels inside and outside of the organization.
• Demonstrates a high level of emotional intelligence.
• Solves difficult problems through rigorous analysis, probing of resources, and by looking beyond the obvious.
• Demonstrates respect.
• Motivated self-learner; works well under pressure in a fast-paced environment.
• Demonstrates a passion for people, service, and results.
• Acts in alignment with core values at all times.

Schedule

Less than 5% travel required.

Essential Physical Demands

The physical demands of this job require manual dexterity to use computers and other standard office equipment.