RCM Specialist III

LOCATION: REMOTE

HOURS: 8-5, M-F

ROLE OVERVIEW

The RCM Specialist III is a senior individual contributor role on the RCM team. Experience across the end-to-end RCM functions from insurance verification, billing, collections, customer services, payment posting, credit balances, and refunds are required for success in this role. A strong candidate will have broad RCM experience and a deep level of expertise in one or more core RCM functions. This role acts as an internal expert for colleagues and leadership, and in addition to having a portfolio of accounts and RCM activities assigned to them for one or more offices, will also assist RCM leadership with special projects, training and content creation, and other tasks. This role supports the central RCM team's overall goal of collecting outstanding balances and enhancing patient financial experiences while maintaining strong relationships with the offices we support and a positive experience for RCM team members.


KEY RESPONSIBILITIES

• Perform all assigned RCM activities in accordance with best practices and internal SOPs. Assigned RCM functions may include, but not limited to:
• Insurance verification and benefits inquiries
• Coding review and compliance with ADA requirements
• Claims submission and rejection management
• Insurance follow-up on outstanding claims, denials and appeals management
• Customer service, statement submission, collection agency placements
• Credit balance resolution and refunds processing
• Insurance and patient payment posting, including $0 pays via manual posting and electronic remittance
• Comply with all functional expectations for productivity and quality standards to meet department goals, and escalate to RCM management concerns over workload volume
• Work closely with key stakeholders for effective cross-organization operations including, providers and front-office teams, accounting/finance, compliance, credentialing and other team members
• Provide ongoing training and development to ensure team members are up-to-date on billing and coding procedures, compliance, payer requirements, and best practices
• Participate in weekly huddles to review site scorecard/metrics, adjust workflows, and implement new strategic initiatives across roles
• Maintain compliance with coding, payer, and patient financial regulations and guidelines to reduce compliance risk, and maximize timely resolution of balances
• Document all patient and payer interactions to maintain a legible history of account activities for transparency with offices, and audit history
• Support RCM management in understanding and self-identifying contributing factors to site-specific RCM KPIs, highlighting areas of concern and areas for improvement. KPIs include but may not be limited to:
• Collection Rate: Monitor and report on the net collection rate, analyzing performance against targets. Collaborate with the team to identify opportunities for improvement.
• Days in AR: Track and evaluate average days in AR to ensure appropriate advanced collection, payment application, efficient and accurate claim filing, and timely back-end billing and claim resolution. Investigate and address any delays or bottlenecks that may be causing extended days in AR.
• % AR Over 90 Days: Review and analyze the percentage of AR over 90 days (insurance v. patient) to identify trends or issues requiring attention. Work with the team to reduce the percentage of aged receivables by implementing strategies to resolve outstanding claims and payments.
• RCM Ticketing: Review speed and effectiveness of resolution of practice needs, account questions, and communication back to practice and/or patient. Ensure response time follows SLA and appropriately addresses initial ask.
• Continuously evaluate RCM processes to identify inefficiencies or areas for improvement. Propose and implement strategies to streamline workflows and improve the net collection rate, reduce days in AR, and lower the percentage of AR over 90 days
• Identify trends in rejections, disputes, payment delays, and denials, and escalate issues for resolution. Always seek the root cause to avoid future issues
• Report any compliance concerns to RCM management, and assist with resolution of compliance issues or discrepancies, working with RCM leadership for transparency and risk management
• Identify gaps in team communication and address problem areas with innovative solutions to improve accountability and performance between team members and within the pod as a whole
• Maintain respect and professionalism in all interactions with internal stakeholders, patients, payers, third parties, and others

ESSENTIAL QUALIFICATIONS

• Prior experience in Dental Office workflows, Revenue Cycle functions to include Scheduling, Registration, Insurance verification, fee schedules, claim submission, charging/coding requirements, insurance AR follow up and payment posting process
• Must be knowledgeable of reimbursement/compliance process and procedures with all payors
• Experience with practice management software systems, insurance portals, clearing houses, insurance guidelines, banking reconciliation software, proficient in intermediate PC skills (MS Office-strong excel skills). Strong computer literacy, Excellent Math and problem-solving skills. Data entry and 10-key by touch.
• Strong interpersonal and organizational skills. Ability to work within a team setting and as an individual contributor. Excellent oral and written communication skills
• Responsible for quality work, meeting deadlines, and adherence to Compliance and Revenue cycle standard operating procedures
• Organized work habits, accuracy, and proven attention to detail with strong analytical skills
• Responsible for quality work, meeting deadlines, and adherence to Compliance and Revenue cycle standard operating procedures
• Certified Professional Coder (CPC) or Certified Revenue Cycle Professional (CRCP) credentials preferred