Revenue Cycle Specialist

Salary Range

$48,500 - $85,400

MAJOR FUNCTION

This position collaborates closely with the Director of Finance and Revenue Cycle, as well as the Revenue Cycle Manager and Revenue Cycle Supervisor, to ensure the seamless execution of day-to-day operations within the Billing Department. Responsibilities include organizing and prioritizing workflows, setting deadlines for finance department staff and external billing vendors, and providing analytical support to other departments on revenue cycle matters. The Revenue Cycle Specialist plays a critical role within our Federally Qualified Health Center (FQHC), overseeing efficient management of financial processes related to patient billing and reimbursement. Key tasks include conducting internal provider billing and coding audits, as well as assisting with claims follow-up. This position is pivotal in optimizing revenue generation and maintaining compliance with healthcare regulations.

ESSENTIAL FUNCTIONS

• Medical Coding:

• Assign accurate medical codes (ICD-10, CPT, HCPCS) to diagnoses and procedures performed by healthcare providers.

• Ensure coding compliance with federal and state regulations, payer policies, and industry standards.

• Review medical records to abstract relevant information for coding purposes.

• Lead and support the CFO, Director of Finance and Revenue Cycle, and finance team in analyzing opportunities for business performance improvement related to coding practices.

• Billing and Claims Management:

• Prepare and submit accurate medical claims to insurance companies or government payers.

• Verify insurance eligibility and benefits for patients, as needed.

• Assist with claims follow-up to promptly resolve billing discrepancies and denials.

• Collaborate with healthcare providers and relevant department staff to resolve billing discrepancies.

• Revenue Integrity:

• Provide analytical support to other departments on revenue cycle issues.

• Monitor billing metrics, generate reports to track revenue performance, and identify areas for improvement.

• Conduct coding audits to ensure coding accuracy and compliance with coding guidelines and regulations. Present best practices based on audits to prevent findings and recommend documentation improvements for maximum reimbursement.

• Identify and rectify coding errors or discrepancies to optimize revenue cycle performance.

• Compliance and Documentation:

• Maintain compliance with coding and billing regulations, including HIPAA, CPT coding guidelines, and local coverage determinations.

• Ensure accurate and complete documentation of patient encounters to support coding and billing processes.

• Conduct internal audits to ensure accuracy and compliance in billing practices.

• Ensure timely and accurate submissions for Medicare and Medicaid WRAP billing and NJ Letter of Agreement (LOA) billing.

• Revenue Analysis and Reporting:

• Generate reports and analyze revenue cycle metrics such as coding accuracy, claim submission timeliness, and denial rates.

• Identify trends, patterns, and opportunities for revenue enhancement or process improvement.

• Present findings and recommendations to management or stakeholders.

• updates to management on billing and collection activities.

ADDITIONAL RESPONSIBILITIES

• Works closely with Revenue Cycle Manager, Supervisor and/or Director to establish priorities in duties/responsibilities
• Work with the Patient Access department (Medical and/or Dental) to resolve billing and registration issues.
• Manage relationships with outsourced revenue cycle vendor(s).
• Attend Medical Staff meetings and deliver special presentations as needed.
• Collaborate with all employees to achieve Henry J. Austin Health Centers goals and objectives, following established policies and procedures.
• Demonstrate willingness and flexibility to perform tasks and projects assigned in the Finance Department.
• Stay updated on healthcare regulations and reimbursement trends to optimize revenue generation.
• Train and educate staff on FQHC billing and coding requirements as needed.
• Oversee month-end and year-end closing processes, as well as external audit preparations.
• Assist in training new staff members on revenue cycle processes and procedures.
• Ability to keep up with multiple deadlines, project goals, and to keep up with high volume of work.
• Performs any additional duties as may be assigned by supervisor, manager or director.
• Works on special projects as needed/assigned.
• Duties, responsibilities and activities may change, or new ones may be assigned at any time with or without notice.

PREREQUISITES

• Minimum of 4-5 years of experience in FQHC settings preferred with an understanding of the workings of City, State and Federal assistance programs such as LOA, HRSA, and Grants.
• Minimum of 2-3 years of billing experience required in a primary care setting.
• Proficiency in Athena EHR system preferred.

LICENSURE AND/OR CERTIFICATIONS

• Certified Professional Coder (CPC) Required.
• Organization reserves the right to request certifications and/or licensures as needed

EDUCATION & EXPERIENCE

• High School Diploma required, bachelor's degree preferred, or some college combined with equivalent experience.
• Knowledge of medical terminology, CPT and ICD-10 coding principles.
• Proficiency in using Electronic Health Records (EHR) and billing software (Athena Preferred).
• Understanding of Medicare, Medicaid, and commercial insurance billing requirements. Provider billing experience, preferably in an FQHC or similar setting (3-5 years) with an understanding of medical insurances ie; Medicare, Medicaid, Managed Care, and Commercial insurances, and a thorough understanding of medical insurance billing basics, ie; charges, allowed amounts, payments, adjustments, denials, capitation, eligibility, coordination of benefits.
• Proficient in word processing and skilled in utilizing Excel and its functionalities.

KNOWLEDGE, SKILLS, ABILITIES AND OTHER (KSAO's)

• Knowledge: Understanding of healthcare billing practices, compliance regulations, and reimbursement methodologies, preferably for FQHC's. Understanding of the workings of City, State and Federal assistance programs such as LOA, HRSA, and Grants.
• Skills: Strong analytical skills, attention to detail, and proficiency in Microsoft Office Suite (Excel, Word). Excellent writing skills with the ability to present high level data and information to senior level staff. Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Abilities: Ability to multitask, prioritize workload, follow through on tasks and work independently as well as part of a team. Must be willing to take ownership of work deliverables to ensure assignments/projects are met in a timely fashion. Ability and willingness to meet critical deadlines. Ability to independently set and achieve goals. Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Other: Strong communication skills, adept in both verbal and written forms. Committed to upholding patient confidentiality and delivering exceptional customer service. Skilled in fostering and maintaining effective working relationships with colleagues. Bilingual proficiency preferred. Demonstrates recognition and respect for cultural diversity. Adheres to dress code standards with a neat and clean appearance. Diligently attends annual reviews and departmental in-services as scheduled.

PHYSICAL & WORK REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position requires manual dexterity sufficient to operate phones, computers and other office equipment. The position requires the physical ability to kneel, bend, and perform light lifting in the amount of 10lbs max. This person must have the ability to write and speak clearly using the English language to convey information and be able to hear at normal speaking levels both in person and over the telephone. Specific vision abilities required by this job include close vision, depth perception and the ability to adjust focus. Generally, the working conditions are good with little or no exposure to extremes in health, safety hazards and/or hazardous materials.