Revenue Cycle Specialist (Hospital Billing, On-Site)

Revenue Cycle Specialist II

The Revenue Cycle Specialist II is responsible for managing the billing process, including handling denials, insurance follow-ups, and appeals based on their tier level in a hospital setting. Ensures accurate and timely submission of claims, works to resolve outstanding balances, and communicates effectively with insurance companies to maximize reimbursement. Collaborates with team members and other departments to maintain compliance with industry regulations and organizational policies, contributing to the overall success of the revenue cycle. May mentor lower-level and newer team members.

Responsibilities

Perform routine follow-ups with payers to ensure timely reimbursement. Review plan guidelines against patient accounts to address claim processing delays effectively. Work on denial resolutions, including claims denied for medical necessity, incomplete documentation, or other issues. Collaborate with clinic staff, registration teams, coding professionals, and medical records staff to address denied claims and prepare accurate appeals. Extract patient treatment details from medical records and coordinate with coding staff to compose individualized appeal letters. Make recommendations to reduce denials by improving billing practices and edit creation. Review and verify all demographic and insurance information using available systems, payer websites, or phone contact with third-party payers. Maintain accurate and complete documentation of all billing and payer-related activities. Respond to inquiries from patients/guarantors, insurance carriers, or internal departments. Stay current with all payer-specific guidelines and industry regulations, including HIPAA compliance. Crosstrain in relevant departmental functions to provide coverage as needed. Resolve outstanding claims in a timely and accurate manner, adhering to departmental policies. Adhere to productivity and quality goals as assigned by the department. Maintain strict confidentiality in all aspects of work. Perform other duties as assigned by the supervisor or manager.

Qualifications

• Review and verify insurance information using technology, applications, payer websites, or by contacting third-party payers or guarantors
• Review adjudicated claims from Medicare, Medicaid, and commercial carriers for appropriate billing.
• Prepare and submit accurate insurance claims and appeals within required timeframes and in accordance with government and payer regulations.
• Analyze plan guidelines against patient accounts to identify and address claim processing delays
• Address denied claims, claims pended for medical necessity, and claims pending supporting documentation by collaborating with clinic, registration, medical records, and coding teams to complete appeals.
• Extract patient treatment information from medical records and work with coding staff to compose appeal letters.
• Make recommendations for billing edits and processes to reduce denials.
• Resolve outstanding claims promptly, adhering to department policies and procedures.
• Respond to inquiries from patients, insurance carriers, or internal departments via telephone or other forms of communication
• Stay current on payer-specific guidelines and regulations Cross-train in department functions to provide backup as needed.
• Assist with training new hospital billing clerks on institutional standards and guidelines.
• Identify workflow improvement opportunities and collaborate with management to implement changes.
• Ensure all work is performed with strict confidentiality. Handle high-level appeals, including preparing documentation and negotiating outcomes with insurance companies.
• Manage escalated claims with significant financial impact, such as underpayments or disputed claims.
• Conduct root cause analysis on recurring billing issues and recommend solutions.
• Collaborate with leadership to set goals and drive improvements in the revenue cycle.
• Participate in revenue cycle audits, focusing on compliance with Medicare and Medicaid requirements.
• Adhere to production and quality goals.
• Perform all other duties as assigned by supervisor or manager.

Required Skills

• Two (2) years of related medical billing experience is required. Epic experience is preferred.