Revenue Cycle Representative

Job Summary: Responsible for performing revenue cycle functions for all medical and/or dental claims for PCC Community Wellness Center, to ensure accurate, timely claim follow up for aged accounts. The Revenue Cycle Rep works collaboratively with Providers, Care Coordinators, Operations, and Revenue Cycle leadership to eliminate department bottlenecks and waist while increasing cash flow and promoting revenue growth.

Essential Duties and Responsibilities:

1. Continually monitor claim volume and aging. Actively follow up on aged pending claims that require resolution or next action for payment for assigned facilities

2. Review, resolve and release claims within 48 hours of claim creation date for assigned facilities

3. Review and resolve 100 claims daily (minimum); yielding reimbursement daily for assigned facilities

4. Resolve state funded claims prior to 180 days outstanding, perform A/R functions on older dates of service with sense of urgency for assigned facilities

5. Resolve federal funded claims prior to 365 days outstanding, perform A/R functions on older dates of service with sense of urgency for assigned facilities

6. Resolve commercial funded claims prior to 90 days outstanding, perform A/R functions on older states of service with a sense of urgency for assigned facilities

7. Initiates write off requests for claims for timely monthly processing for assigned facilities

8. Monitor global transaction report to eliminate incorrect claims adjustments, promoting accurate and timely claim submission for reimbursement for assigned facilities

9. Maintains DSO of <40 days for all assigned facilities
   10. Track EHR third-party billing issues/concerns as they are found to improve billing department bottlenecks and efficiencies using designated tracker

10. Track and monitor provider and site credentialing discrepancies, update designated tracker as needed

11. Perform timely contractual transactions to ensure accurate financial reporting

12. Adherence to all local, state and federal billing guidelines for medical, dental and 340B services provided

13. Adherence to all local, state, and federal billing guidelines for behavioral health and telemedicine services provided

14. Collaborate with PCR site staff to promote patient data accuracy, maintaining a minimum clean claim submission rate of 95% month over month

15. Collaborate with department peers communicating trends and billing errors to promote clean claim submissions for timely reimbursement

16. Accurately submits claim resubmissions through EHR for timely reimbursement; engages EHR for large batch resubmission when supported

17. Under the guidance of department Certified Coder, ensure maximized reimbursement of rendered services through proper claim coding and physician charting

18. Partner with Enrollment Specialist for pending Medicaid enrollment cases to ensure timely update of EHR medical profile and claim submission

19. Operations and Care Coordination Teams to obtain authorizations, consent forms and supporting medical records documents as needed for timely claim processing and maximum reimbursement

20. Track and reports outstanding documentation needed to direct supervisor, during 1:1 weekly meetings

21. Perform audits on denied/rejected claims to understand and execute actions based on findings

22. Ensure all informational coding and billed services align with clinical documentation for claim processing

23. Follow through of internal and external inquiries based on assigned workload, within 24 hours

24. Work with payors through active portals, telephone, fax and in-person appointments to ensure timely follow through of claim processing needs

25. Complies with established policies and procedures, objectives, HIPAA, safety and environmental standards

26. Remain abreast on FQHC/ 340B/ inpatient and dental industry changes, proactive with notifying billing department leaders of any changes

27. Effectively train new hires and counterparts as needed

28. Accomplish projects as a team member or individual as assigned

29. Perform other duties as may be assigned by department leadership and/or executive leadership

Ability to:

• Pivot and accept change to meet the needs of the department and/or organization
• Follow-through, assume responsibility and use good judgment
• Communicate effectively and diplomatically with patients, external insurance and contracting entities and facility personnel both orally and in writing
• Ability to understand and follow verbal and written communication

Experience/Training:

• 2+ years experience in revenue cycle with strong focus on CMS 1500 insurance claims and accounts receivable management required
• Athena EHR experience highly preferred
• Previous FQHC/340B experience highly preferred
• Previous Availity clearinghouse experience preferred
• 2+ years previous experience with local state Medicaid/Managed Care plans
• Cerner EHR experience a plus
• • 2+ years previous experience with commercial payers and EOB interpretation

Technical Knowledge:

Equipment: PC, email, facsimile machine, computerized voice mail system, and common office machines.

Software Knowledge: Windows, MS Office (Word, Excel, PowerPoint), Medical/Dental RCM Software (Athena)

Personal Characteristics:

• Self-motivated and directed with the ability to recognize workflow disruptions ahead of occurrences
• Organized and able to manage competing priorities with tight deadlines
• Detail oriented with the ability to work with minimal supervision
• Willingness to be part of a team-unit and cooperate in the accomplishment of departmental goals and objectives
• Maintain professionalism while navigating challenging interactions