Revenue Cycle Management (Rcm) Review Specialist

Description

JOB SUMMARY

The RCM Aging Specialist is responsible for follow-up on aged accounts by working insurance A/R aging reports (60/90/120+ days) to identify unpaid or underpaid claims and ensure timely, accurate reimbursement from insurance companies. This role requires strong payer communication skills, effective time management, attention to detail, and a working knowledge of reimbursement guidelines, appeals processes, and compliance regulations.

POSITION WITHIN THE ORGANIZATION

1. Reports to Reimbursement Supervisor

2. Cooperates with all departments across the organization

3. Organizes activities with Customer Care, Sales, Commercial and external vendors

4. Participates in:

• Department meetings

• Project meetings

• Working groups

• Project groups

Requirements

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Collects payments due from insurance companies, hospitals, and patients in compliance with CLIA, OIG, and all applicable federal and state regulations.
• Performs follow-up with insurance carriers on claims and appeals when no payment or correspondence has been received within required timeframes.
• Follow up with insurance companies via portals, phone calls, and emails to resolve claim status
• Contacts clients, physician offices, and facilities to obtain medical records required for claim reviews, audits, or appeals.
• Prepares appeal letters and letters of interest for submission to insurance carriers and managed care organizations.
• Review patient balances and determine insurance vs. patient responsibility
• Coordinate with patient billing team when balances roll over to self-pay
• Reviews account files to determine appropriate write-offs based on allowable reimbursement guidelines and submits recommendations to the Reimbursement Supervisor.
• Investigates and prepares refund requests from payers and submits documentation to the Reimbursement Director.
• Negotiates single-claim settlements with insurance carriers and third-party administrators in accordance with department policies.
• Interfaces with insurance representatives, physician offices, and hospitals regarding billing inquiries and service schedules.
• Provides account status and reimbursement data to the sales team as needed.
• Identify trends in denials or delays and report them to leadership or coding/billing teams

EDUCATION AND EXPERIENCE REQUIREMENTS

EDUCATION

• High school diploma or general education degree

EXPERIENCE

• Minimum of 1 year experience in medical billing, accounts receivable, or revenue cycle management (aging and follow-up required).
• Strong Knowledge of EOBs, denial codes, and payer-specific reimbursement rules
• Strong knowledge of insurance claims processing, appeals, reimbursement methodologies, and payer guidelines.
• Familiarity with compliance standards including CLIA, OIG, HIPAA, and other applicable regulations.
• Excellent written and verbal communication skills, including professional payer and patient interaction.
• Ability to negotiate reimbursement effectively and document outcomes accurately.
• Strong analytical, organizational, and time-management skills.
• Proficiency with billing systems, clearinghouses, and Microsoft Office applications.

PREFERRED QUALIFICATIONS

• Experience working with hospital, laboratory, or physician billing environments
• Prior experience handling insurance appeals and payer negotiations
• Experience with XIFIN billing and revenue cycle management systems
• Working knowledge of Salesforce (Sales Force) CRM, including account tracking and reporting
• PRIVACY NOTICE: To review the California privacy notice, click here: https://agendia.com/privacy-policy/
• Employees must not be classified as an excluded individual who is prohibited from participation in any Federal health care program.

BEHAVIOURAL COMPETENCIES/DESIRED SKILLS

• Excellent problem resolution
• Excellent customer service skills
• Outside-the-box thinker

WORKING ENVIRONMENT

Establishes ADA (Americans with Disabilities Act) requirements

ENVIRONMENT/SAFETY/WORK CONDITIONS

Working conditions (inside or outside the office).

• General office environment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Maintains a clean, neat, and orderly work area.
• Adheres to Department Specific Safety Guidelines.
• Standing, sitting, walking, bending, reaching, manual manipulation, and lifting up to 15 pounds.

TRAVEL

• No travel is required

OTHER DUTIES

Other duties as required by management.