Revenue Cycle Specialist

JOB SUMMARY: The Revenue Cycle Specialist is responsible for accurately assigning medical codes to eye care procedures, conducting chart audits to ensure compliance with coding guidelines, and processing insurance claims. This role analyzes medical records to identify chargeable services, collaborates with healthcare providers to maximize reimbursement, responds to insurance audit requests, and assists with appeals and denials related to eye care claims. The specialist also contributes to timely collections by monitoring and working accounts receivable (AR). ESSENTIAL SKILLS AND ABILITIES: Knowledge of basic accounting principles and billing procedures in a healthcare environment. Proficient knowledge of CPT, ICD-10, and HCPCS coding systems and guidelines, with specialized expertise in ophthalmology coding. Strong analytical skills and attention to detail, with the ability to review and interpret complex medical records and documentation. Excellent communication and interpersonal skills, with the ability to collaborate effectively with healthcare providers, insurance representatives, peers, clinic staff, and doctors. Key Responsibilities: Chart Audits and Coding: o Conduct routine chart audits to review medical records and ensure accurate documentation of eye care services provided. o Assign appropriate medical codes (CPT, ICD-10, HCPCS) to diagnoses, procedures, and services performed during eye exams, surgeries, and other treatments. o Ensure compliance with coding guidelines, including documentation requirements for evaluation and management (E/M) services, diagnostic tests, and surgical procedures. Claim Processing and Submission: o Compile and organize charge data from medical records to prepare accurate and complete insurance claims for submission. o Verify patient demographics, insurance coverage, and authorization requirements prior to claim submission. o Submit electronic claims to insurance carriers using billing software or clearinghouse platforms. o Ensure kept and no charges and unbilled charges reports are run regularly to ensure all encounters are billed timely. Insurance Audit Requests: o Respond to insurance audit requests for medical records, coding documentation, and billing information related to eye care claims. o Prepare and submit requested documentation in accordance with audit timelines and requirements. o Collaborate with healthcare providers and clinical staff to gather additional information or clarification as needed. AR Management and Working Denials: o Monitor and manage accounts receivable (AR) related to ophthalmology and optometry claims, including days in AR and aging analysis. o Analyze denials/ads on claims, research, appeal, and overturn denials where appropriate. o Initiate and document appeal/exception workflows; collaborate with providers and payers to resolve issues. o Provide feedback to the clinical team to prevent recurrence of denials. Compliance Training and Education: o Develop and deliver training sessions on coding and documentation requirements, compliance regulations, and best practices for eye care providers and clinical staff. o Stay current on changes to coding guidelines, regulatory requirements, and payer policies and disseminate relevant information to stakeholders. o Provide ongoing support and guidance to healthcare providers and staff on coding-related queries and compliance issues. PHYSICAL REQUIREMENTS: Employee may be required to sit or stand for long periods of time. Must be able to work at a computer for the entirety of the employee's shift. Extensive use of a keyboard and mouse will be required, as well as the ability to use standard office equipment such as not limited to copy machine, fax machine, scanner, softphone headset and postage equipment. EDUCATION AND EXPERIENCE: Required: High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, finance, or related field preferred. Minimum of 3 years of experience in eyecare and proficient knowledge of CPT, ICD-10, and HCPCS coding systems and guidelines. Preferred: Minimum of 3 years of experience in patient accounting, medical billing and insurance processing, preferably in an eye care or healthcare setting. Certified Professional Coder certification or equivalent coding credential preferred. COA/COT certification may be substituted. #J-18808-Ljbffr