Position Summary

The Revenue Cycle Specialist will be responsible for the day-to-day operation in the following areas: billing, claims generation and pre-bill review, A/R follow-up including denials and correspondence processing, credit balance, EDI billing/claim edits, and/or payment posting. Under the direction of the Director, the Specialist will be responsible for handling all functions related to the designated assignment/area and any other duties assigned by management.

Duties and Responsibilities

• Prepares healthcare claims for submission including pre-bill claim edits/review, manual review and update of insurance and other key billing data to assigned insurance, worker compensation or occupational medical payers/employers in accordance with department procedures, Center for Medicare and Medicaid (CMS), Florida Worker Compensation, and other payer/healthcare insurance regulations, rules, and requirements.
  • Provides coverage and assistance to various teams as needed based on fluctuations in volume and priorities.
• Processes payer and patient credit card payments including card on file payment posting daily, or as needed.
  • This includes processing of card on file for debit, credit and health savings or flexible spending cards
  • Payments are processed using Instamed and NextGen systems.
• For Worker Compensation claims, if assigned, provide all necessary documentation required by payors to resolve claim issues or denials, including medical records, prior authorizations, audits, etc.
• Research and complete follow up for outstanding accounts receivable(s) for assigned payers.
  • Follows up with payers, operational managers, revenue cycle team members, and others to ensure accounts receivables are resolve timely, claims are rebilled and appeals submitted timely, when needed.
  • Updates insurance, charge, and other key claims data to ensure proper billing or rebilling.
• Ensure payer and other revenue cycle related correspondence is reviewed, processed, and followed up daily.
  • Obtain and distribute correspondence received by fax, mail and through lockboxes at Bank of America/CashPro or payer portals to appropriate revenue cycle management (RCM) team members including corporate team and offshore RCM teams.
  • Takes appropriate steps to resolve and processes patient statement mail returns.
  • Completes analyze and take appropriate actions to resolve internal and external customer concerns received through Billing Inquiries and other means of communication.
• Provide phone coverage for the Corporate Customer Service Representative (CSR) on site at CareSpot corporate office based on volume or when CSR is out of the office.
  • Provides exceptional customer service and communication to all internal and external customers and team members.
  • Resolves any accounts receivable requests in a timely and accurate manner.
• Completes updates needed from daily NextGen reports. This includes the Employer not on File daily report and others as assigned.
• Other duties and responsibilities as assigned.

Please Note: The list of responsibilities detailed above is not a comprehensive list, nor is it intended to be a list of all responsibilities and duties of the RCM specialist.

Experience, Skills and Education

• 2+ years of relevant healthcare billing, claims submission, payment posting, denials management and or AR follow up experience with outpatient clinic, physician, hospital experience or a combination of areas.
• Deep understanding of CMS 1500 medical billing rules and supporting documentation requirements for Medicare, Medicaid, worker compensation or similar payers.
• Knowledge of ICD-10 diagnosis codes, CPT/HCPCs, use of modifiers, and medical terminology.
• Attention to detail; proven analytical skills and ability to identify trends in denials, claims issues, etc.
• Proficient with Microsoft Office, specifically Excel, Outlook, WORD, Teams, OneNote and SharePoint (or similar tools.
• Experience with healthcare practice management or billing systems. NextGen experience, preferred.
• High School diploma required. Associate degree or above, preferred.
• Bilingual in Spanish, preferred

Physical Demands

The physical demands and work environment characteristics described here are representative of those that must be met by a team member 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 working the essential functions of this job, the employee is frequently sitting, talking, viewing computer screen(s), listening, using hands to handle or feel objects, tools or controls; occasionally required to stand, walk, lift, carry, reach with hands and arms, climb stairs, balance, stoop, kneel, crouch or crawl, and lift and/or move up to 40 pounds.

Work Environment

Admin - While performing the essential functions of the job the employee may be in office or work remotely dependent upon the company and/or department’s policies.