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Revenue Cycle Specialist I


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Title: Revenue Cycle Specialist I

Department: Revenue Cycle Resources

Reports To: Revenue Cycle Supervisor/CBO Office Manager/ Director of Revenue Cycle Services

Supervises: None

Status: Non-Exempt: Full-Time


Position Summary:

The Revenue Cycle Specialist will be responsible for performing all aspects of insurance billing and follow-up functions within their assigned account inventory. They will ensure the timely and accurate submission of claims, follow-up on denied, underpaid, and aging claims, process refund requests, and resolve patient billing inquiries. Furthermore, they will ensure maximum reimbursement for services provided by utilizing sound knowledge of insurance rules and regulations, best practice workflows, and the use of multiple software systems. Compliance with rules and regulations of all applicable federal, state and local laws as well as ruralMED policies is a condition of employment.


Qualifications:

Education and/or Experience:

• High School Diploma is required.
• Associates degree preferred.
• One to three years experience in billing, follow-up, or registration within a hospital or clinic setting is preferred.


General Requirements/Job Duties:

To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The requirements listed below are representative of the knowledge, skill, and/or ability required:

Charge Entry:

  • Receive and review charge entry data from practice sites.
  • Identify and investigate incomplete or missing charges.

 

Billing:

  • Manages and maintains assigned account inventory, completes required reports, and resolves high priority and aged inventory in a timely manner.
  • Processes electronic and paper claims in a timely and accurate manner. Ensures edits to electronic claims meet and satisfy billing compliance guidelines for electronic submission.
  • Resolves clearinghouse and payer rejections daily.
  • Verifies claims adjudication by utilizing appropriate resources and applications.
  • Performs immediate follow-up on underpaid or unpaid insurance claims. Researches, identifies and rectifies any circumstances affecting delayed payment of accounts and takes steps to get claim paid utilizing websites, phone calls to the payers, and/or internal inquiry.
  • Resolves issues holding up timely claim payment, including requests for medical records, coordination of benefit issues, or requests for other information, by coordinating with the responsible department.
  • Resolves denied claims utilizing the payer’s designated reconsideration and appeal processes.
  • Reviews remaining balances on accounts after insurance has paid to ensure the account was processed appropriately and performs the next appropriate action.
  • Resolves overpaid accounts by performing payment review to determine if posting corrections are required or/and a refund is due to the insurance company.
  • Processes incoming correspondence from insurance companies, and performs proper action utilizing internal and external resources.
  • Maintains an account aging process for tracking accounts approaching 30 days past billing date.
  • Processes adjustments or corrections to patient account(s) according to policy guidelines.
  • Receives and resolves inquiries regarding accounts, either in-person, by phone or written correspondence from patients, family members, third-party payers, physicians, etc
  • Accurately and thoroughly documents all actions performed on an account in the appropriate area of the EHR system.
  • Initiates telephone or letter contact to patients to obtain additional information as needed.
  • Communicates issues to management, including payer, system, or escalated account issues. Identifies denial trends and provide suggestions for resolution.

 

Self-Pay:

  • Reduces outstanding self-pay accounts receivable by following self-pay policies and procedures to increase cash collections and reduce bad debt.
  • Make calls to the guarantor/financially responsible parties to follow-up on unpaid self-pay balances.
  • Obtains updated demographic and/or insurance information and verifies new insurance coverage prior to rebilling charges.
  • Accurately and clearly document all interactions with patients or insurance representatives.
  • Assigns accounts to appropriate third-party bad debt collections vendor once internal efforts have been exhausted.

 

Cash Posting:

  • Post payments and adjustments to patient accounts from all insurance payers as well as patient payments.
  • Import all electronic payment files into the current billing system from multiple sources.
  • Review all remittance advice for accuracy to identify errors or questionable data.
  • Research and resolve unapplied/unidentified cash receipts.
  • Reconciles payments and shortages for all batches.
  • Sort & distribute any correspondence from the lockbox to the assigned collector.
  • Scan any items as a backup as necessary

 

Other:

  • Maintains current knowledge of billing and reimbursement rules as designated by the Centers of Medicare and Medicaid Services (CMS), Medicaid Managed Care, and other payers.
  • Maintains proficient knowledge of EHR, clearinghouse, and payer systems, as well as any other systems, required for performing required job duties.
  • Communicates issues to management, including payer, system, or escalated account issues. Identifies denial trends and provide suggestions for resolution.
  • Participates in department meetings, in-service programs, and continuing education programs.
  • Maintains a professional attitude with patients, visitors, physicians, office staff and hospital personnel. Assures confidentiality of patient information, maintaining compliance with policies and procedures.
  • Performs other duties as assigned.


Required Knowledge, Skills and Abilities:

  • Knowledge of medical terminology and/or insurance terminology is preferred.
  • Proficient with Microsoft Office


Security/Access:

• Will have access to primary work location 24 hours a day.
• Will have access to confidential information abiding by the organizations privacy policies and regulations concerning this information.


Equipment Used:

• General office equipment to include: fax, copier, computer, printer, etc.
• Telephone


Patient Age Groups Served:

None.


Essential Work Environment & Physical Requirements:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical ActivityNot ApplicableOccasionally (0-35% of day)Frequently (36-66% of day)Continuous (67-100% of day)
Sitting  X
Standing X 
Walking X 
ClimbingX   
Driving X  
Lifting (Floor to waist level) 40 lbs.10 lbs. 
Lifting (waist level and above) 40 lbs.10 lbs. 
Lifting (Shoulder level and above) 40 lbs.10 lbs. 
Carrying Objects  X 
Push/Pull 40 lbs. 0 lbs.
Twisting X  
Bending X  
Reaching forward X  
Reaching Overhead X  
Squat/kneel/ crawl X  
Wrist Position Deviation   X
Pinching/Fine Motor activities X  
Keyboard use/ repetitive motion   X
TasteX   
Talk   X
Smell X  
Hear   X
Sensory RequirementsNot ApplicableAccurate 20/40Very Accurate 
Near Vision X  
Far Vision X  
 Not ApplicableYesNo 
Color Discrimination X  
 Not ApplicableAccurateMinimalModerate
Depth Perception X  
Hearing X  
Environment Requirements (Occupational Exposure Risk Potential)Not AnticipatedReasonably Anticipated
Bloodborne PathogensX 
ChemicalX 
Airborne Communicable DiseaseX 
Extreme TemperaturesX 
RadiationX 
Uneven Surfaces or ElevationsX 
Extreme Noise LevelsX 
Dust/Particulate MatterX 
Other (Listed)  
Shift Requirements8 hrs/day10 hrs/day12 hrs/dayOther (varied)
Usual workday hoursX   
 Not ApplicableYesNo 
Reliable, punctual attendance for assigned shifts X  
Available to work overtime X  
Telecommuting available? Yes