Revenue Cycle Specialist

SUMMARY:

The Revenue Cycle Specialist is responsible for supporting and overseeing the full outpatient revenue cycle for a multi-disciplinary healthcare organization, including Medical, Dental, Behavioral Health, and Pharmacy services. This role focuses on claim accuracy, revenue maximization (without upcoding), payer compliance, and timely reimbursement through proactive claim review, payment posting, eligibility verification, and accounts receivable follow-up. 

While providers perform initial coding, this position plays a critical quality assurance role by reviewing coding and documentation for accuracy, compliance, and revenue optimization. The Revenue Cycle Specialist also serves as a key resource for providers and staff regarding documentation requirements, payer rules, and revenue cycle best practices. 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Billing & Claims Management 

• Review provider-entered coding for Medical, Dental, Behavioral Health, and Pharmacy services to ensure accuracy, compliance, and optimal reimbursement (without upcoding). 

• Prepare, review, and submit clean electronic claims through the EHR and clearinghouse systems. 

• Identify, correct, and resubmit denied or rejected claims within payer-specific deadlines. 

• Monitor accounts receivable and follow up on unpaid, underpaid, or denied claims. 

Pharmacy Revenue Oversight 

• Review automated pharmacy billing records and reconciliations to ensure accuracy, efficiency, and maximum collections. 

• Investigate discrepancies and coordinate resolution as needed. 

Payment Posting & Reconciliation 

• Post insurance and patient payments accurately and timely on a daily basis. 

• Ensure daily payment posting to TriZetto and related systems. 

• Reconcile payments against expected reimbursement and identify variances. 

Front-End Revenue Integrity 

• Perform daily, ongoing patient checkout functions, including: 

• Verifying insurance eligibility and benefits 

• Confirming accurate patient demographics and insurance information 

• Reviewing coding for accuracy prior to batching claims 

• Obtain prior authorizations when required. 

• These functions are continuous, all-day operational responsibilities. 

Education & Compliance 

• Educate providers and staff on documentation, coding requirements, and payer guidelines. 

• Stay current with ICD-10, CPT, and HCPCS coding updates and payer policy changes. 

• Ensure compliance with HIPAA, state, federal, and payer regulations. 

Reporting & Continuous Improvement 

• Maintain accurate records and prepare reports related to collections, denials, and revenue cycle performance. 

• Participate in ongoing training and continuing education to enhance revenue cycle knowledge and performance. 

Patient Billing Support (Future/As Needed) 

• Patient statements and billing communications are currently automated; this role will support patient billing inquiries and questions if they arise. 

MINIMUM QUALIFICATIONS

Education 

• High school diploma or GED required. 

• Associate degree in healthcare administration, medical billing, or related field preferred. 

• Professional billing or coding certification (e.g., CPC, CCS, or equivalent) preferred but not required; equivalent hands-on experience will be considered. 

Experience 

• 3-5 years of experience in medical billing and revenue cycle operations. 

• Demonstrated experience with claim follow-up, denials, appeals, and payer communications. 

• Knowledge of CPT, ICD-10, and HCPCS coding, including appropriate modifiers. 

• Familiarity with Medicaid, Medicare, and commercial insurance plans. 

Technical Skills 

• Proficiency with EMR/EHR and billing systems. 

• Preferred experience with the following systems: 

• Cerner SPM / PowerChart (Medical & Behavioral Health) 

• Dentrix (Dental) 

• TriZetto (Clearinghouse) 

• Liberty (Pharmacy) 

• Phreesia (Patient communications) 

SKILLS AND COMPETENCIES

• Strong attention to detail and high level of accuracy. 

• Excellent organizational and time-management skills. 

• Ability to manage high-volume, daily transactional work. 

• Strong written and verbal communication skills. 

• Customer service-oriented and solution-focused. 

• Ability to work independently while collaborating effectively with a multidisciplinary team. 

FLSA CLASSIFICATION: EXEMPT