About This Role
The Revenue Cycle Specialist supports the full revenue lifecycle, from claim preparation and submission to accounts receivable follow-up, payment posting, denial management, and coordination of payer authorizations and credentialing activities. This role ensures accurate and timely reimbursement for services while maintaining compliance with payer requirements and organizational policies. The specialist also supports facility and provider credentialing efforts across multiple states, assisting with payer enrollment, documentation tracking, and ensuring billing readiness for new and existing programs.
Responsibilities
- Prepare, review, and submit accurate and timely claims to Medicaid, managed care organizations, commercial insurance companies, and other payers
- Accurately enter charges, review coding (CPT, HCPCS, ICD-10), and ensure proper claim setup prior to submission
- Post payments, adjustments, and denials from EOBs/ERAs into the billing system and reconcile against internal tracking logs
- Perform accounts receivable follow-up on outstanding claims, including investigation of unpaid, underpaid, or denied claims
- Analyze denials, identify root causes, and complete corrections, resubmissions, reconsiderations, and appeals as appropriate
- Communicate with insurance companies and payer representatives to verify benefits, check claim status, resolve discrepancies, and obtain payment
- Verify patient insurance eligibility, benefits, and authorization requirements for various levels of care
- Review clinical documentation and case notes to support authorization requests and communicate effectively with payers regarding medical necessity
- Coordinate with clinical staff and internal departments to ensure services are properly documented, authorized, and billable
- Assist with monthly close activities, including reconciliation of payments, open claims, and revenue reporting
- Identify and communicate issues related to billing, authorization, credentialing, or claim processing that may impact reimbursement
- Assist with payer audits, documentation requests, and compliance reviews as needed
- Collaborate with revenue cycle leadership to improve processes, reduce denials, and increase collection efficiency
- Assist with provider and facility credentialing and re-credentialing processes for Medicaid, managed care organizations (MCOs), and commercial payers across multiple states
- Prepare, collect, and maintain credentialing documentation including licenses, certifications, malpractice insurance, W-9s, and other required materials
- Support provider enrollment in systems such as CAQH, NPI (NPPES), PECOS (if applicable), and state Medicaid portals
- Track credentialing application status, follow up with payers, and escalate delays or issues impacting billing readiness
