Revenue Cycle Specialist

The Revenue Cycle Representative Lead serves as the senior functional resource within the Revenue Cycle department and is responsible for performing tasks pertaining to day-to-day revenue cycle operations while actively supporting KPI's assigned, which may include one or more of the following: claim submission denial resolution, cash posting reconciliation, customer service escalations, authorizations and others revenue cycle KPI's as assigned. The Lead works closely with Revenue Cycle leadership to ensure quality, operational efficiency, and achievement of departmental performance goals. This position provides support in laboratory billing, reimbursement methodologies, payer regulations, denial management, and revenue recovery processes. In addition to performing advanced revenue cycle functions, the Lead serves as a mentor, trainer, and escalation resource for Revenue Cycle Representatives while assisting with workflow management, KPI monitoring, process improvement initiatives, and staff development. The Revenue Cycle Representative Lead plays a critical role in reducing denials, improving collections, minimizing revenue leakage, and enhancing overall financial performance. Essential Duties and Responsibilities: Revenue Cycle Operations Leadership Serve as the primary escalation resource for complex billing, reimbursement, payer, and denial issues. Provide daily guidance and support to Revenue Cycle Representatives. Assist leadership with workload distribution and queue management. Support onboarding and training of new staff. Conduct quality reviews of account documentation, appeals, and follow-up activities. Identify workflow inefficiencies and recommend operational improvements. Assist management with implementation of policies, procedures, and process improvements. Claims Management & Follow-Up Review various reports to drive timely follow-up on unpaid, denied, and underpaid claims. Resolve complex claim reimbursement issues with commercial, Medicare, Medicaid, Managed Medicaid, and other payers. Research claim status through payer portals, clearinghouses, and billing systems. Ensure compliance with payer filing deadlines and appeal timelines. Escalate payer trends and reimbursement barriers to leadership. Denial Management & Appeals Review EOBs, ERAs, remittance notices, and payer correspondence. Review, complex appeals and reconsiderations. Monitor appeal turnaround times and outcomes. Assist in developing denial prevention strategies based on trend analysis. Maintain denial tracking reports and corrective action plans. Accounts Receivable Management Monitor complex payer and patient A/R inventories. Review aging accounts and facilitate timely resolution. Prioritize high-dollar and high-risk accounts. Ensure accurate account documentation and follow-up activities. Monitor team A/R performance and identify recovery opportunities. Payer Relations & Escalation Management Communicate with payer representatives regarding complex claim issues. Assist with provider relations and payer escalation activities. Maintain working knowledge of payer-specific laboratory billing requirements. Participate in payer issue resolution meetings as needed. Track recurring payer challenges and develop corrective action recommendations. Laboratory Revenue Cycle Support Support laboratory-specific billing workflows and reimbursement requirements. Review coding, documentation, diagnosis, medical necessity, and authorization of concerns affecting payment. Collaborate with Coding, Billing, Client Services, Accessioning, Compliance, and Laboratory Operations teams. Identify recurring process breakdowns contributing to denials or lost revenue. Assist with implementation of corrective actions and staff education. Reporting & Performance Monitoring Monitor departmental KPIs, including denial rate, clean claim rate, first pass resolution rate, days in accounts receivable, aging inventory, collection effectiveness rate, appeal success rate, underpayment recovery rate, cash collections, and productivity metrics. Prepare reports and trend analyses for Revenue Cycle leadership. Identify opportunities to improve operational and financial performance. Participate in revenue cycle audits and compliance reviews. Required Qualifications: High School Diploma or GED required. Associate Degree in Healthcare Administration, Business, or related field preferred. Minimum 3 years of healthcare revenue cycle experience. Experience with commercial, Medicare, Medicaid, and Managed Medicaid payers. Strong knowledge of medical billing, claims adjudication, reimbursement methodologies, and payer regulations. Advanced knowledge of EOBs, ERAs, CARC/RARC codes, and appeal processes. Proficiency with billing systems, payer portals, Microsoft Office applications, and reporting tools. Preferred Qualifications: Experience with Medicare LCD and NCD policies. Knowledge of prior authorization requirements and utilization management. Familiarity with CPT, HCPCS, ICD-10-CM, CARC, and RARC coding systems. Experience analyzing denial trends and performance metrics. 401(k) Health insurance Life insurance Vision insurance Experience: Revenue cycle management: 1 year (Required) #J-18808-Ljbffr