REVENUE CYCLE AUDITOR (7:30AM- 4:00PM)

Revenue Cycle Auditor

The Revenue Cycle Auditor is responsible for managing the revenue cycle, which is the process of generating, acquiring, and delivering revenue. Key responsibilities include processing and submitting claims to insurance companies and patients, following up on unpaid claims, resolving discrepancies with payers, ensuring timely collection of payments from insurance companies and patients. The Revenue Cycle Auditor is also responsible for submitting and obtaining all necessary documentation to create revenue for insurance companies. RCA is required to understand and interpret payer contracts and work on and address any complex and intricate revenue-related issues. In addition, RCA will analyze accounts receivable reports, identify repetitive denials, systematic issues, and schedule meetings with payers. RCA needs to identify internal organizational errors arising from other departments and/or system configuration and take appropriate action to resolve them.

Essential Job Functions:

• Process and submit insurance claims to various payers, ensuring accuracy in coding and billing information to minimize denials and delays.
• Review patient accounts to verify correct insurance billing information, update records as necessary, and resolve any discrepancies in patient account balances.
• Analyze denied claims to identify denial reasons and perform the necessary follow-up actions including appealing denied claims with appropriate documentation and justification.
• Analyze accounts receivable reports and take appropriate action to resolve repetitive denials.
• Coordinate with healthcare providers to obtain necessary medical documentation, referrals, or authorizations required for claim processing and reimbursement.
• Discuss areas needing improvement with the authorization and CMN departments as needed.
• Engage directly with patients to explain their bills, resolve billing inquiries, and set up payment plans for outstanding balances, ensuring a positive customer service experience.
• Engage in written communication and schedule meetings with payers to address aging balances.
• Compiles and submits projects to insurance companies.
• Meet with Revenue Cycle Manager and Director to discuss areas of concern.
• Process and submit authorization and CMN requests to medical groups, plans, and physicians' offices. Follow-up in a timely manner.
• Process eligibility verification and determine payer, benefits, and coverage criteria.
• Monitor and report on key performance indicators related to revenue cycle activities, such as claim denial rates, time to payment, and outstanding accounts receivable, to identify areas for improvement.
• Work on complex and intricate revenue-related matters.
• Supports global team and provides feedback though QA, reviews and huddles.
• Monitors work completed by global partners and resolves tasks the global team cannot resolve.
• Submits price table, payer rule, and system configuration updates to designated team.
• Implement and adhere to compliance standards and regulations related to medical billing and coding, maintaining confidentiality of patient information in accordance with HIPAA guidelines.
• Participate in the development and testing of new billing software and systems to improve revenue cycle efficiency, including providing feedback on software performance and suggesting enhancements.

Requirements

Minimum Qualifications:

• Minimum of 2 years' experience in Revenue Cycle Management
• High school diploma or equivalent required
• Effective verbal and written skills
• Knowledge in all major insurance carrier reimbursement guidelines and eligibility coverage and claims processing guidelines (Medicare, Medi-Cal, Commercial Health Plans)
• Thorough understanding of healthcare regulations, coding guidelines, and payer policies/contracts
• Able to work in a fast-paced environment, flexible and ability to adapt to changing environment
• Strong interpersonal, communication, time management, and organizational skills for effectively conveying audit findings to payers as well as with domestic and global staff
• Self-Starter with the ability to work independently
• Proficiency with Microsoft Excel
• Experience with Brightree EHR or other EHR system
• In-depth knowledge of the practices, procedures, and concepts of the healthcare revenue cycle
• Strong analytical and problem-solving abilities
• Working knowledge of MS Office
• Strong ability to analyze financial data, identify discrepancies, and conduct audits
• Exceptional precision in reviewing documents and data for accuracy

Physical Demands and Working Environment

The conditions herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job functions.

Environment: Standard office setting; tasks are regularly performed without exposure to adverse environmental conditions; frequent interaction with staff and the public. The role requires that you wear a headset, access and work within multiple systems while addressing callers' concerns in real time.

Physical: Incumbents require sufficient mobility to work in an office setting; stand or sit for prolonged periods of time; operate office equipment including use of a computer keyboard; light lifting, carrying, pushing and pulling; ability to verbally communicate to exchange information.

Vision: See in the normal visual range with or without correction; vision sufficient to read computer screens and printed documents; and to operate assigned equipment.

NOTE: This job description is not intended to be all-inclusive. Employee may perform other related duties to meet the ongoing needs of the organization.