Women’s Health Connecticut is seeking a highly skilled and detail-oriented Revenue Cycle Medical Claims Specialist to join our Revenue Cycle team in Rocky Hill! This is a hybrid position requiring two – three days in the office. The ideal candidate will be responsible for independently managing complex insurance claims, high-dollar accounts, difficult denials, payer disputes, appeals, and other challenging accounts receivable issues. The candidate must possess a comprehensive understanding of medical billing processes, healthcare claims management, and coding practices. In addition to performing advanced claim follow-up and collection activities, the Claims Specialist II serves as a subject matter resource for payer requirements, claim resolution, denial management, and revenue cycle processes. This position analyzes trends, identifies systemic billing and payer issues, recommends process improvements, and escalates significant financial or operational concerns to management. The Claims Specialist II is expected to exercise a high degree of independent judgment and problem-solving ability and may assist with training, mentoring, quality review, and special revenue cycle projects.
Essential duties and responsibilities:
- Independently manage complex and high-priority insurance accounts throughout the claim resolution and collection process.
- Review aging reports, denial reports, payer reports, system worklists, and other revenue cycle data to identify significant outstanding balances and collection opportunities.
- Investigate complex claim denials, underpayments, incorrect payer processing, bundling issues, authorization issues, timely filing issues, coordination of benefits issues, and other reimbursement discrepancies.
- Conduct comprehensive research to determine root causes of claim denials and payment issues.
- Develop and execute appropriate resolution strategies based on payer-specific guidelines, contractual requirements, billing regulations, and internal procedures.
- Prepare and submit complex reconsiderations, appeals, corrected claims, and supporting documentation within required payer and regulatory timelines.
- Research payer policies, contractual requirements, medical billing guidelines, claim submission processes, and changes affecting reimbursement.
- Identify opportunities to recover previously denied, underpaid, or incorrectly processed claims.
- Review EOBs, ERAs, payer correspondence, and account activity to identify payment variances and systemic reimbursement concerns.
- Utilize payer portals, electronic systems, clearinghouse tools, and internal applications to research claim status and resolve outstanding issues.
- Monitor payer-specific trends and identify recurring denials, processing errors, system issues, or policy changes that may negatively impact revenue.
- Analyze denial and collection trends and communicate findings, financial impact, and recommended corrective actions to management.
- Recommend changes to insurance company guidelines, billing procedures, posting protocols, workflows, and internal processes when recurring issues are identified.
- Partner with coding, customer service, self-pay specialists, posting, payer policy team, and other departments to resolve issues affecting reimbursement.
- Serve as a resource to Level I Claims Specialists by providing guidance on complex claims, payer requirements, and resolution strategies.
- Assist with training and onboarding of new staff and provide ongoing knowledge-sharing related to payer policies and collection practices.
- Assist management with special projects, payer audits, revenue cycle initiatives, and process improvement efforts.
- Participate in identifying opportunities to improve accounts receivable performance, reduce avoidable denials, increase clean claim rates, and accelerate cash collections.
- Maintain detailed and accurate account documentation supporting all collection and appeal activity.
- Escalate significant financial, compliance, payer, contractual, or operational issues to the Revenue Cycle Manager in a timely manner.
- Respond professionally and promptly to requests from internal departments, insurance companies, patients, and other members of the Women’s Health Communities.
- Maintain confidentiality of PHI in accordance with HIPAA, corporate policies, and the minimum necessary standard.
- Adhere to all corporate compliance, safety, and departmental policies and procedures.
- Perform other duties as assigned by management.
Other duties and responsibilities:
- Act as a senior resource and point of contact for complex revenue cycle and payer-related questions.
- Support team productivity, quality, and collection goals.
- Participate in departmental meetings, process-improvement initiatives, payer education, and revenue cycle projects.
- Share knowledge of payer change, denial trends, and best practices with team members and management.
- Assist with development and maintenance of payer-specific workflows, reference materials, and collection procedures.
- Promote consistent application of departmental policies and payer guidelines.
- Demonstrate initiative in identifying opportunities to improve processes and financial performance.
Requirements
- High School Diploma or GED required.
- Minimum of five years of experience in medical insurance collections, healthcare accounts receivable, medical billing, laboratory billing, or a related revenue cycle environment preferred.
- Strong working knowledge of CPT and ICD coding and medical billing practices.
- Advanced understanding of insurance claim processing, EOBs/ERAs, denials, appeals, payer policies, timely filing requirements, authorizations, coordination of benefits, and reimbursement processes.
- Demonstrated ability to independently research and resolve complex insurance claims and accounts receivable issues.
- Proven ability to analyze claim and denial trends and identify root causes.
- Strong critical-thinking, analytical, and problem-solving skills.
- Ability to manage high-priority and complex accounts while meeting productivity and collection deadlines.
- Excellent verbal and written communication skills.
- Ability to communicate effectively with insurance carriers and internal stakeholders and professionally escalate unresolved issues.
- Demonstrated ability to work independently with minimal supervision and exercise sound judgment.
- Strong organizational skills and attention to detail.
- Advanced computer proficiency, including Microsoft Excel, Outlook, Word, OneNote, and applicable revenue cycle, billing, clearinghouse, and payer systems.
- Ability to train, mentor, and serve as a resource to less experienced team members.
The Job responsibilities provided are intended to be a summary of the job duties. In no instance should the duties, responsibilities, and requirements included in a job description constitute as being all-inclusive. The Company and authorized management personnel reserve the right to review, change, add and/or delete duties, responsibilities, and requirements on a job description as necessary.