Revenue Cycle Specialist (Hospital Billing, On-Site)

Responsibilities

• Perform routine follow-ups with payers to ensure timely reimbursement.
• Review plan guidelines against patient accounts to address claim processing delays effectively.
• Work on denial resolutions, including claims denied for medical necessity, incomplete documentation, or other issues.
• Collaborate with clinic staff, registration teams, coding professionals, and medical records staff to address denied claims and prepare accurate appeals.
• Extract patient treatment details from medical records and coordinate with coding staff to compose individualized appeal letters.
• Make recommendations to reduce denials by improving billing practices and edit creation.
• Review and verify all demographic and insurance information using available systems, payer websites, or phone contact with third-party payers.
• Maintain accurate and complete documentation of all billing and payer-related activities.
• Respond to inquiries from patients/guarantors, insurance carriers, or internal departments.
• Stay current with all payer-specific guidelines and industry regulations, including HIPAA compliance.
• Crosstrain in relevant departmental functions to provide coverage as needed.
• Resolve outstanding claims in a timely and accurate manner, adhering to departmental policies.
• Adhere to productivity and quality goals as assigned by the department.
• Maintain strict confidentiality in all aspects of work.
• Perform other duties as assigned by the supervisor or manager.

Qualifications

• Review and verify insurance information using technology, applications, payer websites, or by contacting third-party payers or guarantors.
• Analyze plan guidelines against patient accounts to identify and address claim processing delays.
• Prepare and submit accurate insurance claims and appeals within required timeframes and in accordance with government and payer regulations.
• Address denied claims, claims pended for medical necessity, and claims pending supporting documentation by collaborating with clinic, registration, medical records, and coding teams to complete appeals.
• Extract patient treatment information from medical records and work with coding staff to compose appeal letters.
• Make recommendations for billing edits and processes to reduce denials.
• Resolve outstanding claims promptly, adhering to department policies and procedures.
• Respond to inquiries from patients, insurance carriers, or internal departments via telephone or other forms of communication.
• Stay current on payer-specific guidelines and regulations.
• Cross-train in department functions to provide backup as needed.
• Aid in training new hospital billing clerks on institutional standards and guidelines.
• Identify workflow improvement opportunities and collaborate with management to implement changes.
• Ensure all work is performed with strict confidentiality.
• Handle high-level appeals, including preparing documentation and negotiating outcomes with insurance companies.
• Manage escalated claims with significant financial impact, such as underpayments or disputed claims.
• Conduct root cause analysis on recurring billing issues and recommend solutions.
• Collaborate with leadership to set goals and drive improvements in the revenue cycle.
• Participate in revenue cycle audits, focusing on compliance with Medicare and Medicaid requirements.
• Adhere to production and quality goals.
• Perform all other duties as assigned by supervisor or manager.