Revenue Cycle Specialist

Position Summary

The Revenue Cycle Specialist is responsible for managing and optimizing the organization’s revenue cycle processes to ensure accurate billing, timely reimbursement, and compliance with healthcare regulations. This role supports financial performance by overseeing claim submission, payment posting, denial management, and account resolution while delivering excellent service to patients, payers, and internal stakeholders. This is a on-site position, not a remote position.

Key Responsibilities

Billing & Claims Management

• Prepare, review, and submit accurate claims to insurance payers and government programs.
• Ensure coding, documentation, and charge capture align with payer and regulatory requirements.
• Monitor claim edits, rejections, and clearinghouse reports; resolve issues promptly.
• Track claim status and follow up to ensure timely adjudication.

Denial Management & Collections

• Investigate and resolve denied or underpaid claims.
• Identify denial trends and recommend corrective actions.
• Prepare and submit appeals with appropriate supporting documentation.
• Work aging reports to reduce accounts receivable (A/R) days.

Payment Posting & Reconciliation

• Post payments accurately from electronic remittances (ERA/EOB).
• Reconcile daily deposits and ensure alignment with general ledger processes.
• Identify payment discrepancies and escalate when necessary.

Patient Account Resolution

• Respond to patient billing inquiries with professionalism and clarity.
• Establish payment plans and assist patients in understanding financial responsibility.
• Maintain confidentiality and compliance with HIPAA guidelines.

Compliance & Regulatory Adherence

• Ensure all billing activities comply with federal, state, and payer-specific regulations.
• Maintain knowledge of CMS guidelines, payer policies, and reimbursement methodologies.
• Support internal and external audits by providing required documentation.

Reporting & Process Improvement

• Analyze A/R, denial rates, and reimbursement patterns.
• Assist in preparing monthly revenue cycle performance reports.
• Recommend workflow improvements to increase efficiency and reduce revenue leakage.
• Participate in system optimization and training initiatives.

Required Qualifications

• High school diploma or equivalent required; associate or bachelor’s degree in healthcare administration, Finance, or related field preferred.
• 2–4 years of experience in medical billing, revenue cycle, or healthcare finance.
• Knowledge of CPT, ICD-10, and HCPCS coding principles (working knowledge required; certification a plus).
• Experience with electronic health records (EHR) and practice management systems.
• Strong understanding of insurance verification claims lifecycle, and reimbursement processes.
• Proficiency in Microsoft Office, particularly Excel.

Preferred Certifications (if applicable)

• Certified Revenue Cycle Specialist (CRCS)
• Certified Professional Biller (CPB)
• Certified Healthcare Financial Professional (CHFP)

Core Competencies

• Attention to detail and accuracy
• Analytical and problem-solving skills
• Strong organizational and time-management abilities
• Excellent communication and customer service skills
• Ability to work independently while meeting productivity goals
• Commitment to compliance, confidentiality, and ethical standards

Key Performance Indicators (KPIs)

• Days in Accounts Receivable (A/R)
• Clean Claim Rate
• Denial Rate and Appeal Success Rate
• Net Collection Percentage
• Timely Filing Compliance
• Patient Account Resolution Timeliness

Work Environment

This position operates in a professional office or healthcare environment and may require prolonged computer use. Remote or hybrid work may be available depending on organizational needs.

Physical Requirements

• Prolonged sitting and computer use
• Ability to review detailed financial and medical documentation
• Occasional lifting of files or materials (up to 15 lbs.)