Revenue Cycle Specialist (RCM)

Job Details

Description

Job Summary:

Under the general direction of the Revenue Cycle Manager, the Revenue Cycle Specialist is responsible for processing the company's third-party medical claims. This includes preparing and submitting claims to Medicaid, Medicare, Community Mental Health, Commercial Insurance, and private insurance. The role involves addressing questions, complaints, or issues from insurance companies, Medicaid offices, Managed Care Plans, Medicare regions, Health Maintenance Organizations, and other adjusters. The specialist will monitor accounts to identify overdue payments, maintain accurate records, and report on collections activity. Meeting and exceeding established Key Performance Indicators (KPIs) and departmental metrics are essential.

This position offers flexibility to work fully remote, in-office, or in a hybrid arrangement. However, hybrid or fully remote options will be available only after successful completion of training and demonstration of confidence in the role.

Job Description

• Verifying all the information for claims billing and accounts receivable is correct.
• Contact the appropriate person to obtain missing or unclear billing information.
• Facilitate charge capture.
• Ensure all billing charges are captured appropriately.
• Identify, analyze, and reconcile documentation issues, omissions, and errors.
• Review all funding invoices to determine the correct billing method.
• Complete claim forms through Inovalon (Clearing House), SanData (Billing Software), and PCE/Funding Portals (CMH), ensuring all required fields are complete and accurate.
• Attach required documentation for payment.
• Follow up by phone on all unpaid and denied claims through activities in SanData.
• Determine and execute the next course of action, which may include rebilling missing claims, addressing denials, or sending additional information on pending claims.
• Complete all necessary follow-up in a timely manner to avoid payment delays. Stay current on follow-ups to meet billing/collection deadlines.
• Respond to and interact with external funding personnel regarding all aspects of billing through phone, email, portal, or regular mail promptly and courteously.
• Relay changes in Medicaid, MCO, Medicare, and HMO regulations discovered by claim denials to all pertinent personnel, including the Financial Clearance Team.
• Discuss issues identified at the claims portion of the funding process that would affect the prior authorization portion with the Financial Clearance Specialist.
• Relay updated information regarding state policy changes to the department.
• Maintain confidentiality as outlined in the privacy portion of the federal Health Information Privacy and Portability Act of 1996.
• Perform the filing for the department.
• Undertake other duties/projects assigned by the Director of Finance.
  

Metrics/KPIs (Key Performance Indicators)

100% of items marked "Ok to Bill" are invoiced by the end of business on Friday.

100% of unbilled lines have the appropriate status by the end of business on Friday.

Submit complete, clean claims.

Review and update the status of aged accounts receivable (A/R) > 60, < 180 days.

Fully satisfying aged A/R > 180 days.

Complete claims marked as "resubmit" within 24 hours.

Education

• Required: High School Diploma or equivalent.
• Required: Must be knowledgeable in billing databases. Medical billing experience is desirable.
• Preferred: Associate Degree in Business, Finance, Health Information Management, or a related field.
• Preferred: 3 years of experience in Healthcare Billing (Michigan CMH preferred).
  
  

Qualifications

• Proficient in Medicare billing and practices.
• Experienced with working with a Clearing House (preferably Inovalon).
• Excellent computer knowledge and accurate keyboard skills (minimum of 35 WPM with 90% accuracy).
• The ability to work in a constantly changing environment, with good judgment skills and attention to detail.
• Excellent organizational skills and the ability to prioritize and coordinate workload with high proficiency and accuracy.
• Strong analytical and problem-solving skills.
• Ability to work cooperatively with other departments.
• Ability to work independently and follow through on tasks without direct supervision.
• Ability to work well under pressure in a flexible, diplomatic, and expeditious manner.
• Maintain strict confidentiality of patients' medical records and adherence to all HIPAA policies and regulations.
• Extremely accurate with attention to details, policies, and procedures.
• Proficient in using Microsoft Excel, Word, and Outlook.
• Good overall knowledge of Eisenhower Center departments and their functions.
  
  

Span Of Control

This position is responsible for key revenue cycle generation processes that impact the company's cash flow, including establishing hard-copy and computerized files, entering third-party billing information and subsequent medical billings, and ensuring all documentation is present and claims are billed timely and accurately.