Revenue Cycle Specialist

Position Summary:The Revenue Cycle Specialist is responsible for supporting the full revenue lifecycle, including claim preparation and submission, accounts receivable follow-up, payment posting, denial management, and coordination of payer authorizations and credentialing activities. This role ensures accurate and timely reimbursement for services rendered while maintaining compliance with payer requirements, Medicaid, managed care organizations (MCOs), and commercial payers’ guidelines, and organizational policies.The Revenue Cycle Specialist will also support facility and provider credentialing efforts across multiple states, assisting with payer enrollment, documentation tracking, and ensuring billing readiness for new and existing programs. This position works closely with clinical, administrative, and director of revenue cycle to resolve billing and credentialing issues, verify benefits, obtain authorizations, and support the overall revenue cycle process.Essential Job Functions:Prepare, review, and submit accurate and timely claims to Medicaid, managed care organizations, commercial insurance companies, and other payers.Accurately enter charges, review coding (CPT, HCPCS, ICD-10), and ensure proper claim setup prior to submission.Post payments, adjustments, and denials from EOBs/ERAs into the billing system and reconcile against internal tracking logs.Perform accounts receivable follow-up on outstanding claims, including investigation of unpaid, underpaid, or denied claims.Analyze denials, identify root causes, and complete corrections, resubmissions, reconsiderations, and appeals as appropriate.Communicate with insurance companies and payer representatives to verify benefits, check claim status, resolve discrepancies, and obtain payment.Verify patient insurance eligibility, benefits, and authorization requirements for various levels of care.Review clinical documentation and case notes to support authorization requests and communicate effectively with payers regarding medical necessity.Coordinate with clinical staff and internal departments to ensure services are properly documented, authorized, and billable.Assist with monthly close activities, including reconciliation of payments, open claims, and revenue reporting.Identify and communicate issues related to billing, authorization, credentialing, or claim processing that may impact reimbursement.Assist with payer audits, documentation requests, and compliance reviews as needed.Collaborate with revenue cycle leadership to improve processes, reduce denials, and increase collection efficiency.Credentialing Support Functions:Assist with provider and facility credentialing and re-credentialing processes for Medicaid, managed care organizations (MCOs), and commercial payers across multiple states.Prepare, collect, and maintain credentialing documentation including licenses, certifications, malpractice insurance, W-9s, and other required materials.Support provider enrollment in systems such as CAQH, NPI (NPPES), PECOS (if applicable), and state Medicaid portals.Track credentialing application status, follow up with payers, and escalate delays or issues impacting billing readiness.Ensure providers and facilities are properly enrolled, linked, and active with payers prior to claim submission.Identify credentialing gaps or errors that may result in claim denials or non-par payment status and communicate issues to leadership.Maintain credentialing logs and ensure all provider information is current, accurate, and compliant with payer and regulatory requirements.Assist with payer communications related to credentialing, contracting, and enrollment updates.Coordinate with internal teams to support new program or location launches by ensuring credentialing and payer setup are completed timely.Support audit readiness by maintaining organized and accessible credentialing documentation.Essential Qualifications:Certifications/Licenses:Ability to pass criminal and Medicaid background clearance as required.Ability to obtain CPR and First Aid Certification and annual Tuberculosis testing as required.Billing and Coding Certification (CPC, CCS, or equivalent) preferred but not required.Compliance with all applicable organizational, state, and federal requirements, including vaccination or testing requirements as mandated.Education:High School Diploma or equivalent required.Associate’s degree or higher in Healthcare Administration, Business Administration, Accounting, or related field preferred.Relevant work experience may be substituted for formal education.Experience and Competencies:Ability to work collaboratively with others in a manner that is pleasant and professional.Minimum of 2 years of experience in medical billing, accounts receivable, credentialing, or revenue cycle operations.Experience with Medicaid, managed care organizations (MCOs), and commercial insurance billing preferred.Experience with provider credentialing and payer enrollment processes preferred.Experience with behavioral health or substance use disorder billing preferred.Familiarity with authorization processes, utilization review, and level of care criteria (e.g., ASAM) preferred.Experience working with electronic medical records (EMR), billing systems, and clearinghouses.Basic/intermediate understanding of insurance contracts, language, codes and claim submission.Attention to detail.Ability to operate a computer and complete documents in Microsoft Word program formats or the ability to learn.Ability to complete work tasks within scheduled work hours.Excellent verbal and written communication skills.Working Conditions:Work is primarily performed in an office settingPHYSICAL DEMANDS:Occasional lifting of more than 10 pounds.Sitting, standing, walking, reaching are performed in the normal course of the position.The normal work routine involves no exposure to blood, body fluids, or tissues, BUT exposure or potential exposure may be required as a condition of employment. Appropriate personal protective equipment will be readily available to every employee engaged in Category II tasks. #J-18808-Ljbffr WESTCARE FOUNDATION INC