Revenue Cycle Specialist I

Summary

The Revenue Cycle Specialist I supports backend revenue cycle work, primarily after claims have been submitted. The specialist works assigned account and claim queues to research unpaid claims, denials, payment discrepancies, and other outstanding balances. The role also coordinates with the organization’s outsourced RCM partner to resolve issues and keep accounts moving toward payment.

Work is assigned and prioritized by the Revenue Cycle Supervisor. The specialist documents each action, follows up within required timeframes, and escalates issues that require advanced review or a decision outside the role’s authority.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

· Work assigned accounts and claims from designated billing system queues, denial queues, reports, or task lists.

· Review claim history, remittance advice, payer responses, account notes, and supporting documentation to determine the next action.

· Follow up on unpaid, denied, rejected, or underpaid claims through payer portals, calls, or other approved channels, as assigned.

· Correct routine account or claim issues within established procedures and route items requiring coding, clinical, registration, or authorization review to the appropriate team.

· Respond to account-level questions and requests from the outsourced RCM partner, providing information needed to continue claim follow-up.

· Track items referred to the outsourced partner or internal teams and validates that assigned issues are resolved or appropriately escalated.

· Identify recurring denial reasons, payer delays, and queue trends; report findings to the supervisor.

· Record actions taken, payer responses, next steps, and follow-up dates in the billing system.

· Meet department standards for queue productivity, account accuracy, timely follow-up, and documentation.

· Protect patient and financial information and follow organizational privacy and billing policies.

Supervisory Responsibilities

· None

Qualifications

To perform this job successfully, an individual must be able to accomplish each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

· Experience working insurance accounts receivable or denial queues.

· Experience coordinating account resolution with an outsourced RCM or billing partner.

· Familiarity with Medicare, Medicaid, commercial insurance, remittance advice, claim status, and common denial reasons.

Education and/or Experience

· High school diploma or equivalent.

· One year of experience in medical billing, insurance follow-up, denial management, patient accounts, or a related healthcare revenue cycle role; relevant training may substitute for experience.

· Ability to review account details, follow written procedures, and determine appropriate next steps.

· Strong attention to detail, organization, communication, and problem-solving skills.

· Ability to manage an assigned workload and use electronic health record, billing, payer portal, and spreadsheet tools.

Computer Skills

To perform this job successfully, an individual should have proficient computer skills, including Microsoft Office (specifically Outlook, Excel, Word, and PowerPoint) and Adobe Acrobat.

Physical Demands 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.

· While performing the duties of this Job, the employee is regularly required to sit, stand, and walk, as well as reach with hands and arms and talk or hear.

· The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds.

· Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision and ability to adjust focus.

Work Environment The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this job.

· The noise level in the work environment is usually moderate.