Revenue Cycle Management Specialist

Roles and Responsibilities of a Revenue Cycle Management (RCM) Specialist

Overview

A Revenue Cycle Management (RCM) Specialist is essential in ensuring the financial health and operational efficiency of a healthcare organization. In this role, the specialist is responsible for verifying insurance eligibility, submitting claims, and resolving payment discrepancies. The specialist addresses insurance denials, works on insurance correspondence, and ensures accurate billing as per payer guidelines. They also assist with patient account inquiries and perform billing audits to ensure all services are properly captured. This position requires proactive management of accounts receivables, analyzing reporting to reduce AR, and staying current on payer requirements to ensure compliance.

Essential Responsibilities

• Verify insurance eligibility and benefits for patients.
• Submit electronic and paper claims.
• Review and analyze denials to determine the best course of action based on denial and remark codes.
• Work on insurance correspondence, remittance advice, and submit corrected claims or appeals to resolve denials and collect payments.
• Examine corrected claims to ensure proper billing as per LCD or payer guidelines.
• Identify and communicate trends and issues with insurance denials and billing edits.
• Respond to patient account inquiries and provide billing statements, payment receipts, itemized statements, and billing records as requested.
• Perform billing audits to ensure all services were properly captured by RCM.
• Review coding denials and provide resolution or suggestions to coders based on LCD or payer guidelines.
• Post payments from ERA and paper EOPs.
• Download and import ERA files from clearinghouses or payer direct web portals.
• Review and resolve underpayments and refund requests.
• Make insurance collection calls.
• Communicate effectively with other departments to resolve billing, claims, or credentialing issues.
• Proactively manage and follow up on accounts receivables (AR) aged greater than 45 days and maintain all RCM work-queues.
• Analyze reporting and analytics to reduce AR by contacting payers and escalating issues to resolve unpaid or underpaid claims.
• Stay current on payer requirements and other pertinent industry knowledge via research to ensure guidelines and procedures are met for each payer.
• Perform projects and additional daily reports.
• Perform other duties as assigned.

Requirements

Certifications