RCM Specialist I

KEY RESPONSIBILITIES

• Perform all assigned RCM activities in accordance with best practices and internal SOPs.
• Verify insurance coverage and benefits for scheduled patients using payer portals or phone calls.
• Accurately enter and update insurance information in the practice management system.
• Confirm eligibility, plan limitations, and coordination of benefits to ensure claims are submitted cleanly in the appropriate billing order.
• Submit pre-determination and pre-authorizations requested by the patient or supporting practices with all necessary clinical attachments, follow-up on processing status, and notify practice of status return in a timely manner ensuring treatment is not delayed.
• Prepare and submit claims (electronic, paper, or via portal) in accordance with payer-specific requirements and timelines.
• Review rejected claims, identify causes, and resubmit corrected claims as needed.
• Respond promptly and professionally to patient and office inquiries related to billing, insurance coverage, and balances.
• Assist in creating and sending patient statements and following up on outstanding balances as directed.
• Document all insurance verification results, pre-authorization and claim submissions, and patient interactions thoroughly and clearly.
• Escalate issues related to claim delays, system errors, or patient concerns to the appropriate RCM team members or supervisors.
• Maintain compliance with HIPAA, payer guidelines, and internal policies.
• Participate in team meetings and training sessions to stay current on processes, tools, and payer updates.
• Support other RCM functions as needed to ensure a smooth and efficient revenue cycle process.
• Support RCM management in understanding and self-identifying contributing factors to site-specific RCM KPIs, highlighting areas of concern and areas for improvement. KPIs include but may not be limited to:
• Collection Rate: Monitor and report on the net collection rate, analyzing performance against targets. Collaborate with the team to identify opportunities for improvement.
• Days in AR: Track and evaluate average days in AR to ensure appropriate advanced collection, payment application, efficient and accurate claim filing, and timely back-end billing and claim resolution. Investigate and address any delays or bottlenecks that may be causing extended days in AR.