Revenue Cycle Specialist

Revenue Cycle Specialist

The Revenue Cycle Specialist is responsible for the timely processing and follow-up on claims submitted to insurance companies and other entities for payment. Analyzes and reviews insurance claims for accuracy, completeness, and eligibility. Reviews claims for eligibility to be reimbursed. Maintains updated records and prepares required documentation. Assists in controlling the cost of processing claims. Contacts policyholders about claims and may provide information regarding the amount of benefits. Additionally, this position is responsible for performing more in-depth review of claims to determine appropriate actions to recover claim payments. Usually assigned to provide leadership and ongoing guidance to other team members assigned to same/similar project.

Hiring Requirements

• Bachelor's degree or equivalent experience preferred
• Prior Supervisory or training experience preferred
• Minimum of 5 years of experience in specialty insurance billing or collections required, including submitting and following up on claims
• Experience in Dental, Hospital or Physician Billing and Collections preferred
• Proficiency with MS Office and Excel
• Knowledge of a variety of hospital, physician and/or dental billing systems required.
• Knowledge of a variety of insurance online systems as well as online status/ eligibility inquiry sites required
• Knowledge of general insurance guidelines a plus.

Responsibilities

Essential Responsibilities

• Read, evaluate, and appropriately analyze Explanation of Benefits (EOB) for accuracy and determination of appropriate follow up actions with insurance companies.
• Analyze dental records and other applicable information for determination of appropriate appeal process.
• Reviewing and preparing claims for electronic and hard copy billing submission
• Responsible for providing research and root cause analysis for claim remediation
• Standard documentation in dental billing system for tracking processes and follow up needed
• Uses pertinent data and facts to identify and solve a range of problems within area of expertise
• Submit on a timely basis to insurance companies' dental and medical claims for processing.
• Identifying and correct billing errors and resubmitting claims to insurance carriers
• Providing review and remittance advice for payment errors, denials, and under payments
• Follow up on unpaid claims within standard billing cycle time frames.
• Call insurance companies regarding payments and denials and to check on EOBs.
• Identify and bill secondary or tertiary insurances.
• Answer all patient or insurance company telephone inquiries pertaining to assigned accounts.
• Research and follows-up on client questions regarding statements and patient balances.
• Update the billing system with changes to insurance information and notes regarding progress as well as alerts for Operations staff to collect on co-pay, etc.
• Research the accuracy of patient balances, including resolution of outstanding claims, determine that the patient has received the appropriate correspondence regarding his/her account, make patient calls for balances above certain $ thresholds, turn over accounts to collection agency with appropriate documentation, review collection agency invoices for accuracy/correct office assignment, monitor collection folders for direct pays, correct account addresses based on USPS files.
• Reviews adjustment reports requiring intimate knowledge of claim filing and claim payment tabs.
• Detect payer and provider trends that are indicative of underlying coverage issues and payer issues.
• Detailed understanding of how insurance coverages are set up, including procedures and category tabs and how to adjust coverages as needed.
• Analyze the appropriateness of discount code write offs
• Identifies provider credentialing issues.
• Works with EDI Support and/or credentialing team to address and correct.
• Identifies areas of revenue leakage and revenue opportunities and proposes Improvis or operational enhancements to address.
• Perform other duties as assigned.

Qualifications

Knowledge and Skills

• Excellent analytical skills, solutions orientated
• Ability to handle sensitive material confidentially
• Analyzes and investigates
• Provides explanations and interpretations within area of expertise
• Excellent Analytical skills
• Strong written and verbal communication skills
• Ability to work independently
• Ability to multi-task, this includes ability to understand multiple products and multiple levels of benefits within each project
• Ability to communicate with PC leadership regarding complex insurance issues, using influence to reach desired outcome
• Solid understanding of how to reallocate payments to procedures
• Identify, manage and correct complex process issues.

Attributes

• Builds constructive and effective relationships and establishes credibility; gains the trust of others through open communication and honest, constructive feedback
• Put's the needs of the organization first and acts with the customer in mind
• Relates well to people at all levels inside and outside of the organization
• Demonstrates a high level of emotional intelligence
• Solves difficult problems through rigorous analysis, probing of resources and by looking beyond the obvious
• Demonstrates respect
• Motivated self-learner; works well under pressure / fast paced environment
• Demonstrates a passion for people, service and results
• Acts in alignment with ADPI's core values at all times

Travel Requirements: Less than 5%

Essential Physical Demands: The physical demands of this job require manual dexterity to use computers and other standard office equipment.