Revenue Cycle Specialist

SUMMARY: The Revenue Cycle Specialist is responsible for researching, correcting, resubmitting, and resolving medical claims that have been rejected, denied, underpaid, or otherwise not processed correctly by insurance payers. This position focuses on identifying the causes of claim issues, coordinating necessary corrections with internal departments and external payers, and following claims through to resolution.

The Medical Billing Specialist works closely with the Billing Technician, Business Office Manager, providers, coding staff, clinical departments, and insurance representatives to resolve billing issues, reduce preventable denials, and support appropriate reimbursement for services provided by the Health Center.

ESSENTIAL DUTIES AND RESPONSIBILITIES will include the following:

Electronic Clearinghouse Rejections

- Monitor the designated electronic clearinghouse for rejected claims, submission errors, and other claim transmission issues.

- Review and address electronic clearinghouse rejections promptly upon receipt.

- Research rejection reasons and determine the appropriate corrective action.

- Correct and resubmit claims when issues can be resolved within the scope of the position.

- Coordinate with the Billing Technician, registration, coding staff, providers, or other departments when additional information or corrections are required.

- Document rejection reasons, actions taken, outstanding issues, and follow-up plans.

- Monitor unresolved rejections until corrected and resubmitted or otherwise appropriately resolved.

- Ensure no rejection remains unaddressed or without documented follow-up.

Denied Claims and Corrected Claim Submission

- Review remittance advice, explanations of benefits (EOBs), denial reports, and claim status information to identify denied or incorrectly processed claims.

- Research denial codes, payer explanations, claim history, billing requirements, and supporting documentation to determine the reason for denial.

- Correct claim information and coordinate necessary documentation or coding clarification.

- Prepare and submit corrected claims, resubmissions, reconsiderations, and appeals as appropriate.

- Verify that corrections address the original rejection or denial reason before resubmission.

- Track corrected claims to confirm receipt and monitor payer processing.

- Maintain documentation of denial reasons, corrective actions, resubmission dates, payer responses, and outcomes.

- Escalate claims requiring management review, clinical clarification, or additional intervention.

Denial Research and Resolution

- Investigate recurring and complex denials to identify root causes and prevent repeated billing errors.

- Research payer policies, eligibility issues, authorization requirements, filing limits, coding requirements, and documentation requirements relevant to denied claims.

- Contact insurance representatives and use payer portals to clarify denial reasons, claim status, payment decisions, and required corrective actions.

- Coordinate with providers, coding staff, and clinical departments to obtain missing or corrected information.

- Prepare and submit appeals or reconsideration requests within applicable payer deadlines when appropriate.

- Monitor appealed claims until a determination is received.

- Identify recurring denial trends and report significant issues to the Business Office Manager.

Unpaid and Incorrectly Processed Claims

- Research unpaid, pending, underpaid, and incorrectly processed claims to determine the cause and appropriate resolution.

- Follow up with payers regarding claims that remain unpaid or have not been processed correctly.

- Review discrepancies between billed amounts, payer adjudication, remittance advice, and expected reimbursement.

- Determine whether claim correction, resubmission, additional documentation, reconsideration, or appeal is appropriate.

- Monitor claims approaching timely filing limits, appeal deadlines, and other payer-specific timeframes.

- Maintain a tracking system documenting claim status, actions taken, outstanding issues, and follow-up dates.

- Escalate unresolved claims with significant financial impact or barriers to resolution to the Business Office Manager.

- Continue follow-up until the claim is resolved, appropriately escalated, or closed with documented justification.

Prior Authorization-Related Claim Issues

- Research claim denials related to missing, incomplete, expired, or mismatched prior authorizations.

- Coordinate with appropriate clinical or administrative staff to obtain authorization information or supporting documentation.

- Communicate authorization-related claim issues to the responsible department.

- Monitor corrected claims related to authorization issues to determine whether the payer has processed them.

- Document actions taken and escalate unresolved issues as appropriate.

This responsibility focuses on authorization issues affecting claim payment. Routine prior authorization requests remain with designated staff unless otherwise assigned.

Documentation and Process Improvement

- Maintain accurate records of rejections, denials, corrected claims, appeals, payer communications, and resolution efforts.

- Ensure unresolved items have documented actions, next steps, and follow-up dates.

- Coordinate with the Billing Technician and other departments to address recurring claim issues.

- Identify opportunities to reduce preventable rejections and denials and improve claim resolution.

- Assist with billing reviews, payer audits, and quality improvement activities as assigned.

- Maintain knowledge of payer policies, claim correction procedures, appeal requirements, and applicable billing guidelines.

Confidentiality and Compliance

- Protect patient confidentiality and the security of health records and other confidential information.

- Comply with applicable privacy and security laws, including HIPAA and the Privacy Act of 1974 when applicable, and Health Center policies.

- Follow applicable payer requirements and established Health Center procedures.

- Perform other related duties within the scope of the position as assigned by the Business Office Manager.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform the essential duties satisfactorily. The requirements listed below represent the knowledge, skills, and abilities needed for the position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

EDUCATION AND EXPERIENCE:

- Associate of Arts (AA) degree or at least two (2) years of relevant work experience in medical billing, healthcare administration, insurance claims processing, accounts receivable, or a related field.

- Ability to research billing issues, identify errors, follow established procedures, and complete corrective actions accurately and promptly.

- Strong attention to detail and ability to organize work, meet deadlines, maintain accurate documentation, and communicate effectively with internal departments and insurance payers.

- Ability to learn and apply insurance payer requirements, claim correction procedures, and denial resolution processes.

- Experience reviewing electronic clearinghouse rejections, insurance denials, and payment discrepancies.

- Experience correcting and resubmitting claims, researching unpaid claims, or assisting with appeals and reconsiderations.

- Familiarity with electronic clearinghouses, payer portals, electronic health records, or practice management systems.

- Knowledge of Medicare, Medicaid, commercial insurance, managed care plans, and payer billing requirements.

- Familiarity with ICD-10-CM, CPT, and HCPCS coding concepts.

- Medical billing certification, such as Certified Professional Biller (CPB), or medical coding certification, such as Certified Professional Coder (CPC).

- Experience working in a Tribal Health, Indian Health Service (IHS), community health center, or similar healthcare setting.

CERTIFICATES, LICENSES, AND/OR REGISTRATIONS:

- Medical billing or coding certification is preferred but not required.

KNOWLEDGE, SKILLS, AND ABILITIES:

- Ability to research and resolve claim rejections, denials, and billing discrepancies.

- Ability to learn payer-specific correction, resubmission, reconsideration, and appeal requirements.

- Strong organizational, analytical, and problem-solving skills.

- Effective written and verbal communication skills.

- Ability to recognize recurring billing issues and communicate potential solutions.

- Ability to maintain accurate records and protect confidential patient information.

- Proficiency with standard computer applications, including Microsoft Word and Excel, and the ability to learn designated billing systems and electronic clearinghouse tools.

- Ability to work independently, manage competing priorities, meet deadlines, and seek assistance when necessary.

- Ability to coordinate professionally with internal departments and external insurance representatives.

PLEASE NOTE: P.L. 93-638, Indian Preference and Tribal Employment Rights Ordinance, (TERO), will be practiced, however all qualified applicants will be considered.

IF YOU ARE INTERESTED, PLEASE SEND APPLICATIONS RESUME TO:

OMAHA TRIBE OF NEBRASKA

ATTN: HR DEPARTMENT

P.O. BOX 368

MACY, NEBRASKA 68039

OR

EMAIL: [email protected]