Revenue Cycle Specialist

Overview: The Revenue Cycle Specialist manages the financial aspects of patient care by accurately coding diagnoses and treatments, submitting claims to insurance companies, addressing billing inquiries, resolving all payment denials, ensuring timely and accurate reimbursement, while meeting department productivity and quality requirements.

Key Responsibilities of a Medical Billing Specialist:

• Privacy: Maintain HIPAA standards at all levels of interaction, ensuring patient confidentiality and upholding a strong code of ethics.
• Accurate and Timely Coding: Translate healthcare services and procedures into standardized codes (ICD-10, CPT, HCPCS)
• Claim Submission: Prepare and submit electronic or paper claims to insurance companies.
• Insurance Verification: Verify patient insurance eligibility and coverage.
• Claim Follow-up: Monitor claim status, address denials, and resolving billing issues.
• Patient Billing: Bill patients for any outstanding balances and copays.
• Payment Processing: Post payments and adjustments to patient encounters.
• Data Entry: Accurately enter patient and claim data into billing systems.
• Communication: Respond to patient inquiries and resolve billing concerns.
• Payment Plans: Work with patients to develop reasonable payment plans.
• Record Keeping: Maintain accurate and organized billing records and notes.

Duties and Responsibilities:

• Perform work queue resolution of medical billing charge sessions by reviewing clinical documentation to confirm diagnostic (ICD-10) and procedural (CPT/HCPCS/ADA) codes and modifiers, based on charge review edits. May perform manual charge entry for hospital related services. Ensure all charge review edits are appropriately resolved utilizing claim judgement and critical thinking skills.
• Verify all information required to submit a clean claim, including provider, place of service, date of service, bill area, all codes, and special billing procedures defined by a payer, contract, or PCHC. Ensure accuracy in the coding and claim submission process to avoid errors and rejections. Interact professionally with providers, nurses, health center staff and all PCHC employees to verify accurate billing information.
• Use current electronic health record (EHR) systems and billing software to input, update, and manage patient demographic information, insurance details, and billing records accurately and securely.
• Monitor and track the status of medical and dental claims using the billing system and work queues. Identify and resolve claim denials, rejections and unpaid claims. Follow up with payers to resolve denied claims and ensure timely reimbursement.
• Respond to billing inquiries from patients, insurance companies, and healthcare providers. Research claim status, resolve billing discrepancies, and communicating effectively to ensure timely payment and resolution of issues.
• Maintain up-to-date knowledge of healthcare billing regulations, coding guidelines, and payer policies. Ensure compliance with HIPAA, CMS, and other regulatory requirements governing medical billing practices.
• Utilize current EHR system workflows for payment posting and reconciliation. Post insurance and patient payments to accounts accurately and in a timely manner. Reconcile encounters to ensure payments match billed amounts and address any discrepancies. Understand Explanation of Benefits (EOBs) received from insurance companies and use the information to properly record denial and payment codes.
• Maintain a complete online file of all remittance advice (RA) in PDF format for auditing purposes.
• Research, identify, and accurately post all unidentified (unapplied) payments including self-pay credit balances.
• Review and resolve outstanding credits. Using the data from the EHR, identify credits and resolve over-posted encounters and true overpayments made by either the patient or insurance carriers by refunding when applicable.
• Document trends and issues causing claim edits, incorrect posting, or payment denials. Report to the management team to collaborate for a resolution.

Qualifications:

• Proficient in medical terminology, including CPT, HCPCS, and ICD-10 coding.
• Experience with the EPIC Electronic Health Record, Professional Billing System, and web-based applications and websites.
• Certified Professional Coder (preferred but not required), with working knowledge of CPT, HCPCS, Modifiers and ICD-10 codes.
• Working knowledge of how to resolve unpaid or denied claims to ensure timely payment.
• Experience with electronic/clearinghouse billing software. Able to identify, resolve, or work collaboratively with management team to resolve claim formatting issues.
• Demonstrated knowledge of Federal payer regulations, third party payers, HIPAA rules, reimbursement policies and procedures. Proven ability to interpret and apply guidelines.
• Strong multi-tasking skills and consistent attention to detail.
• Ability to effectively communicate with team members to resolve questions regarding collaboration and assignments. Demonstrated strong interpersonal, verbal and written communication skills.
• Knowledge of HIPPA Regulations.
• Excellent computer skills, including experience with Microsoft Word, Excel, and Outlook (emails and calendars).
• Fluent in Spanish (preferred, not required).

Education:

• High School diploma or equivalent required.
• Certified Professional Coder with AAPC (American Academy of Professional Coders) preferred, not required.
• Two to three years' experience as a medical biller, payment posting, or healthcare finance.

Essential Job Functions:

• Ability to read, comprehend, and apply standard operating procedures. Ability to effectively present information by telephone and in one-on-one situations to patients and employees.

• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers.

• Ability to apply common sense understanding to carry out instructions furnished in written or oral form. Ability to deal with problems involving several variables in standardized situations.

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear.

• The employee is occasionally required to stand; balance; and stoop.

• The employee must regularly lift and/or move up to 10 pounds.

• Specific vision abilities required by this job include close vision, distance vision, color vision, and ability to adjust focus.

• The noise level in the work environment is usually moderate.

• Employee must be able to give accurate/tactful explanations to visitors, patients, and fellow workers and remain professional in stressful situations; accurately recognize names, detect/avoid errors in scheduling and message taking; exhibit the courtesy required to work productively with others under stressful conditions; exercise patience.

Summary of Occupational Exposure:

Classified by CDC as Low Risk.