Revenue Cycle Specialist

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Position Summary

Reporting to the Director of Revenue Cycle Management, Revenue Cycle Manager, and/or designee, the Revenue Cycle Specialist is responsible for supporting revenue cycle operations through accurate insurance verification, eligibility management, patient registration support, claims follow-up, payment posting, accounts receivable management, and patient account resolution. This position plays a critical role in maximizing reimbursement, reducing claim denials, improving patient access, and ensuring timely collection of revenue for services rendered.

The Revenue Cycle Specialist utilizes electronic health record (EHR), practice management systems, payer portals, and internal reporting tools to ensure accurate patient information, insurance coverage verification, charge capture, billing compliance, and follow-up activities. The incumbent actively monitors revenue cycle performance indicators and collaborates with Patient Access, Clinical Operations, Billing, and Finance teams to improve financial outcomes and patient experience.

This position routinely interacts with patients, providers, management, insurance companies, managed care organizations (MCOs), government agencies, vendors, contractors, and other stakeholders while maintaining strict confidentiality in accordance with HIPAA regulations.

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Essential Duties and Responsibilities

Insurance Verification and Eligibility Management

• Verify patient insurance eligibility, benefits, and coverage prior to services being rendered.
• Determine appropriate financial class and accurately coordinate primary, secondary, and tertiary insurance coverage.
• Maintain current knowledge of payer regulations, billing requirements, and coverage policies.
• Review and update patient demographic and insurance information within the electronic health record and practice management system.
• Monitor patients approaching Medicaid renewal deadlines and conduct outreach to assist with coverage retention.
• Assist patients with managed care PCP assignments and PCP changes to prevent claim denials and delays in care.
• Manage and update patient alerts related to insurance coverage, eligibility, demographic information, and payer requirements.
• Review Sliding Fee Scale applications for completeness and accuracy and assist with error resolution.

Revenue Cycle Operations

• Process, monitor, and reconcile daily encounters and charges.
• Ensure timely submission and resolution of claims billed to government and commercial payers.
• Perform accounts receivable follow-up on unpaid, denied, rejected, and underpaid claims.
• Research claim denials and prepare appeals with supporting documentation.
• Track and resolve outstanding accounts to maintain aging goals and organizational collection standards.
• Process patient statements and perform collection follow-up in accordance with organizational policies.
• Document all account activity accurately and timely within the billing system.
• Identify and resolve credit balances, overpayments, and refund requests.
• Process and reconcile Explanation of Benefits (EOBs), Electronic Remittance Advice (ERAs), and related payment transactions.
• Enter and reconcile daily payment postings and adjustments.

Dental and Special Program Billing

• Process and reconcile dental encounters and associated billing activities.
• Track vouchers and prepare billing documentation and monthly statements for designated public assistance programs and contracted services.
• Support billing and reimbursement activities for grant-funded and special program services.

Patient Service and Outreach

• Respond professionally to patient billing inquiries by telephone, electronic communication, and in-person interactions.
• Assist patients in understanding insurance benefits, billing statements, payment responsibilities, and available financial assistance programs.
• Conduct outreach to high-risk no-show patients to improve appointment compliance and continuity of care.
• Support telehealth registration, eligibility verification, and patient onboarding processes.

Reporting and Analytics

• Prepare and maintain reports, spreadsheets, and databases using Microsoft Office applications.
• Assist with revenue cycle performance reporting, including key performance indicators (KPIs), aging reports, denial trends, eligibility outcomes, and coverage retention metrics.
• Support the preparation of monthly operational and financial reports.
• Assist management with audits, reconciliations, and revenue cycle improvement initiatives.

Operational Support

• Assist with auditing daily encounters, registrations, and billing activities to ensure accuracy and compliance.
• Support implementation and optimization of Healow Check-In, patient kiosks, telehealth tools, and other patient engagement technologies.
• Participate in special projects, audits, system implementations, and process improvement initiatives.
• Cross-train in Patient Access Specialist (PAS) responsibilities and provide coverage when operational needs require.
• Collaborate effectively with internal departments to ensure seamless patient access and revenue cycle processes.
• Perform other duties as assigned to support organizational goals and patient care delivery.

Compliance and Confidentiality

• Maintain compliance with all federal, state, payer, and organizational regulations governing healthcare billing and reimbursement.
• Access and utilize Protected Health Information (PHI) only as necessary to perform assigned job duties.
• Adhere to HIPAA privacy, security, and confidentiality requirements at all times.

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Minimum Qualifications

Education

• High School Diploma or equivalent required.
• Associate degree or post-secondary education in Healthcare Administration, Business Administration, Finance, Medical Billing, or related field preferred.

Experience

• Minimum two (2) years of experience in revenue cycle operations, medical billing, patient access, insurance verification, accounts receivable, collections, or healthcare customer service preferred.
• Experience working in a Federally Qualified Health Center (FQHC), community health center, physician practice, hospital, dental practice, or similar healthcare environment preferred.
• Experience with electronic health records (EHR) and practice management systems preferred.

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Knowledge, Skills, and Abilities

• Knowledge of medical terminology, CPT, HCPCS, and ICD-10 coding principles.
• Understanding of healthcare reimbursement methodologies, insurance coverage rules, coordination of benefits, and claims adjudication processes.
• Knowledge of Medicare, Medicaid, Managed Care Organizations, and commercial insurance plans.
• Proficiency in Microsoft Office Suite, including Excel, Word, Outlook, and PowerPoint.
• Strong analytical, organizational, and problem-solving skills.
• Ability to prioritize multiple tasks while meeting deadlines in a fast-paced environment.
• Excellent verbal and written communication skills.
• Strong customer service and patient relations skills.
• Ability to interpret billing, eligibility, and reimbursement information accurately.
• Ability to maintain confidentiality and exercise sound judgment.
• Ability to work independently and collaboratively within a team environment.
• Commitment to providing exceptional patient-centered service.

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Licenses and Certifications

Preferred but not required:

• Certified Revenue Cycle Specialist (CRCS) - AAHAM
• Certified Revenue Cycle Representative (CRCR) - HFMA
• Certified Professional Biller (CPB) - AAPC
• Other applicable revenue cycle, billing, or healthcare certifications

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Physical Requirements

The physical demands described here are representative of those required to successfully perform the essential functions of this position.

• Ability to communicate effectively through verbal and written means.
• Ability to sit, stand, walk, bend, reach, and perform repetitive motions as necessary.
• Ability to occasionally lift, carry, push, or pull objects weighing up to 25 pounds.
• Ability to effectively operate office equipment including computers, telephones, scanners, copiers, and related technology.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

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Work Environment

Work is primarily performed in a professional healthcare office environment. The position may require interaction across multiple clinical and administrative locations and may involve exposure to typical healthcare operational settings.