The Revenue Cycle Specialist II is responsible for managing the billing process in a hospital setting, including denials, insurance follow-ups, and appeals. This role ensures accurate and timely claim submission, works to resolve outstanding balances, and communicates with insurance companies to maximize reimbursement. The specialist collaborates with team members and other departments to maintain compliance with industry regulations and organizational policies and may mentor lower-level and newer team members.
Responsibilities include:
- Perform routine follow-ups with payers to ensure timely reimbursement.
- Review plan guidelines against patient accounts to address claim processing delays.
- Work on denial resolutions, including claims denied for medical necessity, incomplete documentation, or other issues.
- Collaborate with clinic staff, registration teams, coding professionals, and medical records staff to address denied claims and prepare accurate appeals.
- Extract patient treatment details from medical records and coordinate with coding staff to compose individualized appeal letters.
- Recommend improvements to billing practices and edit creation to reduce denials.
- Review and verify demographic and insurance information using available systems, payer websites, or phone contact with third-party payers.
- Maintain accurate and complete documentation of all billing and payer-related activities.
- Respond to inquiries from patients, guarantors, insurance carriers, or internal departments.
- Stay current with payer-specific guidelines and industry regulations, including HIPAA compliance.
- Cross-train in relevant departmental functions to provide coverage as needed.
- Resolve outstanding claims in a timely and accurate manner.
- Adhere to productivity and quality goals.
- Maintain strict confidentiality in all aspects of work.
Requirements & Qualifications
- Two years of related medical billing experience required.
- Epic experience preferred.
- Ability to review and verify insurance information using technology, applications, payer websites, or by contacting third-party payers or guarantors.
- Ability to review adjudicated claims from Medicare, Medicaid, and commercial carriers.
- Ability to prepare and submit accurate insurance claims and appeals within required timeframes and in accordance with government and payer regulations.
- Ability to analyze plan guidelines against patient accounts to identify and address claim processing delays.
- Ability to address denied claims and claims pending supporting documentation by collaborating with clinic, registration, medical records, and coding teams.
- Ability to extract patient treatment information from medical records and work with coding staff to compose appeal letters.
- Ability to resolve outstanding claims promptly and respond to inquiries from patients, insurance carriers, or internal departments.
- Ability to stay current on payer-specific guidelines and regulations.
- Ability to assist with training new hospital billing clerks and identify workflow improvement opportunities.
- Ability to handle escalated claims, conduct root cause analysis, and support revenue cycle audits.
Location
San Antonio, Texas, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
3 weeks ago