The Revenue Cycle Specialist III manages the billing process, including handling denials, insurance follow-ups, and appeals based on their tier level in a hospital setting. Ensure accurate and timely submission of claims, work to resolve outstanding balances, and communicate 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. Works with the billing management team to submit the necessary documentation to insurance providers to facilitate claim processing while identifying and escalating billing inefficiencies. Recommend process improvements. Serves as a subject matter expert in hospital-based billing, and handles escalated level appeals high-level claim denials, and resolves escalated billing issues, ensuring full compliance with hospital and medical industry standards. May mentor lower-level and newer team members.

Highly detail-oriented with advanced organizational and prioritization skills, capable of managing complex and high-priority projects concurrently. Expert proficiency in Microsoft Word, Excel, PowerPoint, and email software (e.g., Lotus Notes). Exceptional verbal and written communication skills, including drafting high-level memorandums, letters, and official correspondence. Expert knowledge of hospital billing, appeals processes, and denial management, with the ability to handle complex payer disputes and escalated claims. In-depth understanding of Medicare/Medicaid rules, regulations, and industry trends. Strong familiarity with industry best practices in revenue cycle management. Proficient in navigating office software, billing systems, and abstracting tools, with demonstrated expertise in using coding resources. Advanced understanding of insurance authorizations, benefits, coverage, and eligibility as they relate to medical billing. Expertise in reimbursement practices and payer-specific requirements, ensuring compliance and optimal reimbursement Ability to mentor and guide Tier 1 and Tier 2 billers in billing processes and denial resolutions. Expertise in conducting root cause analysis and providing solutions to recurring billing issues. Stay current on payer-specific guidelines, industry trends, and regulatory requirements to ensure compliance and billing efficiency Must possess expert knowledge of hospital-based billing processes, including appeals and denial management, and demonstrate a proven ability to handle complex payer disputes while negotiating favorable outcomes Comprehensive understanding of payer-specific rules, as well as federal and state regulations, and industry trends, is essential. Advanced problem-solving and critical thinking skills are required, along with strong leadership and mentorship abilities to support team development Exceptional organizational skills and the ability to efficiently manage high volumes of work.

Review and verify insurance information using technology, applications, payer websites, or by contacting third-party payers or guarantors Review adjudicated claims from Medicare, Medicaid, and commercial carriers for appropriate billing. Prepare and submit accurate insurance claims and appeals within required timeframes and in accordance with government and payer regulations. Analyze plan guidelines against patient accounts to identify and address claim processing delays Address denied claims, claims pended for medical necessity, and claims pending supporting documentation by collaborating with clinic, registration, medical records, and coding teams to complete appeals. Extract patient treatment information from medical records and work with coding staff to compose appeal letters. Make recommendations for billing edits and processes to reduce denials. Resolve outstanding claims promptly, adhering to department policies and procedures. Respond to inquiries from patients, insurance carriers, or internal departments via telephone or other forms of communication Stay current on payer-specific guidelines and regulations Cross-train in department functions to provide backup as needed. Assist with training new hospital billing clerks on institutional standards and guidelines. Identify workflow improvement opportunities and collaborate with management to implement changes. Ensure all work is performed with strict confidentiality. Handle high-level appeals, including preparing documentation and negotiating outcomes with insurance companies. Manage escalated claims with significant financial impact, such as underpayments or disputed claims. Conduct root cause analysis on recurring billing issues and recommend solutions. Collaborate with leadership to set goals and drive improvements in the revenue cycle. Participate in revenue cycle audits, focusing on compliance with Medicare and Medicaid requirements. Adhere to production and quality goals. Perform all other duties as assigned by supervisor or manager.