Revenue Cycle Representative

Job Summary: Responsible for performing revenue cycle functions for all medical and/or dental claims for PCC Community Wellness Center, to ensure accurate, timely claim follow up for aged accounts. The Revenue Cycle Rep works collaboratively with Providers, Care Coordinators, Operations, and Revenue Cycle leadership to eliminate department bottlenecks and waist while increasing cash flow and promoting revenue growth.

Essential Duties And Responsibilities

Continually monitor claim volume and aging. Actively follow up on aged pending claims that require resolution or next action for payment for assigned facilities

Review, resolve and release claims within 48 hours of claim creation date for assigned facilities

Review and resolve 100 claims daily (minimum); yielding reimbursement daily for assigned facilities

Resolve state funded claims prior to 180 days outstanding, perform A/R functions on older dates of service with sense of urgency for assigned facilities

Resolve federal funded claims prior to 365 days outstanding, perform A/R functions on older dates of service with sense of urgency for assigned facilities

Resolve commercial funded claims prior to 90 days outstanding, perform A/R functions on older states of service with a sense of urgency for assigned facilities

Initiates write off requests for claims for timely monthly processing for assigned facilities

Monitor global transaction report to eliminate incorrect claims adjustments, promoting accurate and timely claim submission for reimbursement for assigned facilities

Maintains DSO of <40 days for all assigned facilities

Track EHR third-party billing issues/concerns as they are found to improve billing department bottlenecks and efficiencies using designated tracker

• Track and monitor provider and site credentialing discrepancies, update designated tracker as needed
• Perform timely contractual transactions to ensure accurate financial reporting
• Adherence to all local, state and federal billing guidelines for medical, dental and 340B services provided
• Adherence to all local, state, and federal billing guidelines for behavioral health and telemedicine services provided
• Collaborate with PCR site staff to promote patient data accuracy, maintaining a minimum clean claim submission rate of 95% month over month
• Collaborate with department peers communicating trends and billing errors to promote clean claim submissions for timely reimbursement
• Accurately submits claim resubmissions through EHR for timely reimbursement; engages EHR for large batch resubmission when supported
• Under the guidance of department Certified Coder, ensure maximized reimbursement of rendered services through proper claim coding and physician charting
• Partner with Enrollment Specialist for pending Medicaid enrollment cases to ensure timely update of EHR medical profile and claim submission
• Operations and Care Coordination Teams to obtain authorizations, consent forms and supporting medical records documents as needed for timely claim processing and maximum reimbursement
• Track and reports outstanding documentation needed to direct supervisor, during 1:1 weekly meetings
• Perform audits on denied/rejected claims to understand and execute actions based on findings
• Ensure all informational coding and billed services align with clinical documentation for claim processing
• Follow through of internal and external inquiries based on assigned workload, within 24 hours
• Work with payors through active portals, telephone, fax and in-person appointments to ensure timely follow through of claim processing needs
• Complies with established policies and procedures, objectives, HIPAA, safety and environmental standards
• Remain abreast on FQHC/ 340B/ inpatient and dental industry changes, proactive with notifying billing department leaders of any changes
• Effectively train new hires and counterparts as needed
• Accomplish projects as a team member or individual as assigned
• Perform other duties as may be assigned by department leadership and/or executive leadership