Job Description

The Certified Accounts Receivable Specialist is responsible for pursuing reimbursement of services rendered and achieving accounts receivable resolution. This role involves resolving insurance carrier denials, appealing claims, contacting carriers regarding open accounts, and responding to insurance carrier correspondence and inquiries while demonstrating flexibility with assignments within professional scope/duties/licensure. The specialist will work with various payers, including Medicare, Medicaid, and commercial insurers, ensuring compliance with all relevant regulations.

Essential Duties

Claims Management & Resolution:

• Consistently meet or exceed productivity and quality standards for claim edits, complaint claim submissions, and clinical documentation requirements.
• Ensure timely filing of claims, resulting in clean, complete, and accurate submissions.
• Perform timely follow-up on denials and appeals, including root cause analysis to reduce/prevent future denials while working to overturn denials for payment resolution.
• Submit specialist provider appeals denied for medical necessity, coding/bundling issues, experimental, and technical reasons.

Coding & Charge Corrections:

• Analyze coding-related denials to determine coding integrity and take appropriate actions, including charge corrections, appeals to payers, or submission to the Coding team for further review.
• Perform charge corrections to add or modify appropriate CPT modifiers after reviewing physician documentation according to CPT guidelines.
• Maintain the coding mailbox and handle necessary charge corrections identified by the coding/billing department, including modifications of modifiers, diagnosis codes, and CPT corrections.

Payer Interaction & Compliance:

• Maintain compliant follow-up correspondence with third-party payers regarding outstanding accounts receivables using various communication methods (e.g., statements, emails, faxes).
• Understand and apply payer medical and coverage policies to determine the medical necessity of specialist procedures, surgeries, injections, and therapies.
• Understand and adhere to Medicare billing requirements and those of other assigned payers as defined by contracts, state, or federal law.
• Practice HIPAA privacy standards and ensure compliance with patient health information privacy practices.

Reporting & Analysis:

• Review and analyze coding-related denials and report trends to management/sites for feedback to providers.
• Identify opportunities for customer, system, and process improvements and submit them to management.
• Update registration information, post denial codes, and adjustments in practice management systems.
• Recommend accounts for contractual or administrative write-offs with appropriate justification and documentation.

Customer Service & Support:

• Assist with overflow incoming customer service calls, billing, or payment posting when needed.
• Provide excellent communication and service when dealing with patients, families, public, co-workers, and professional offices.

Preferred Experience

• Two years of college or a college degree.
• Knowledge of Epic systems.

Required Licensure/Education

• High school graduate or equivalent.
• Physician coding certification (CPC through AAPC or CCA through AHIMA) within 6 months of hire.
• At least 2 years of related work experience.
• Working knowledge of physician billing and follow-up, including an understanding of insurance rules and regulations.
• Knowledge of HIPAA standards and the ability to perform mathematical calculations.
• Excellent communication skills and basic knowledge of medical terminology and billing practices.
• Extensive experience and knowledge of PC applications, including Microsoft Office and Excel.

Employee Health Requirements

Exposure/Sensory Requirements

Exposure to:

Chemicals: None

Video Display Terminals: Extreme

Blood and Body Fluids: None

TB or Airborne Pathogens: None.

Sensory requirements (speech, vision, smell, hearing, touch):

Speech: Needed for presentations/training, telephone communication, facilitate meetings.

Vision: Needed to read memos and literature.

Smell: N/A

Hearing: Needed for telephone communications, meetings, and listening to employee concerns.

Touch: Need to write, do computer entry, filing.

Activity/Lifting Requirements

Percentage of time during the normal workday the employee is required to:

Sit: 85%

Twist: 0%

Stand: 5%

Crawl: 0%

Walk: 5%

Kneel: 0%

Lift: 2%

Drive: 0%

Squat: 1%

Climb: 0%

Bend: 1%

Reach above shoulders: 1%

The weight required to be lifted each normal workday according to the continuum described below:

Up to 10 lbs: Occasionally

Up to 20 lbs: Occasionally

Up to 35 lbs: Not Required

Up to 50 lbs: Not Required

Up to 75 lbs: Not Required

Up to 100 lbs: Not Required

Over 100 lbs: Not Required

Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.): Lifting is not usually required.

Maximum consecutive time (minutes) during the normal workday for each activity:

Sit: 408

Twist: 0

Stand: 24

Crawl: 0

Walk: 24

Kneel:0

Lift: 9

Drive: 0

Squat: 8

Climb: 0

Bend: 8

Reach above shoulders: 4

Repetitive use of hands (Frequency indicated):

Simple grasp up to 10 lbs. Normal weight: 5- 10# frequent

Pushing & pulling Normal weight:

Fine Manipulation: Terminal entry, calculator.

Repetitive use of foot or feet in operating machine control: None

Environmental Factors &Special Hazards

Environmental Factors (Time Spent):

Inside hours: 40

Outside hours : 0

Temperature: Normal Range

Lighting: Average

Noise levels: Average

Humidity: Normal Range

Atmosphere: Dust &Poor Ventilation

Special Hazards: None

Protective Clothing Required: None

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

Our Commitment to You:

Riverside Healthcare offers a comprehensive suite of Total Rewards: benefits and nationally rated employee well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so your journey at and away from work is remarkable. Our Total Rewards package includes:

Compensation

• Base compensation within the position’s pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift differential, on-call
• Opportunity for annual increases based on performance

Benefits and more

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Health Savings and Flexible Spending Accounts for eligible health care and dependent care expenses
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

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