Revenue Cycle Specialist II (Hospital Billing)

The Revenue Cycle Specialist II is responsible for managing the billing process, including handling denials, insurance follow-ups, and appeals based on their tier level in a hospital setting. Ensures accurate and timely submission of claims, works to resolve outstanding balances, and communicates effectively with insurance companies to maximize reimbursement. Collaborates with team members and other departments to maintain compliance with industry regulations and organizational policies, contributing to the overall success of the revenue cycle. May mentor lower-level and newer team members.

• Perform routine follow-ups with payers to ensure timely reimbursement.
• Review plan guidelines against patient accounts to address claim processing delays effectively.
• 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.
• Make recommendations to reduce denials by improving billing practices and edit creation.
• Review and verify all 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 all payer-specific guidelines and industry regulations, including HIPAA compliance.
• Crosstrain in relevant departmental functions to provide coverage as needed.
• Resolve outstanding claims in a timely and accurate manner, adhering to departmental policies.
• Adhere to productivity and quality goals as assigned by the department.
• Maintain strict confidentiality in all aspects of work.
• Perform other duties as assigned by the supervisor or manager.

EDUCATION:

• High School/ GED required