Revenue Cycle Reimbursement Specialist

Position Overview

Reporting to the Director of Reimbursement, the Revenue Cycle Specialist is responsible for managing and resolving outstanding medical claims to support timely and maximum reimbursement. This position plays an important role within the orthopedic revenue cycle management process and requires strong knowledge of medical billing, medical collections, accounts receivable, insurance verification, denial management, appeals, payment posting, medical coding, and explanation of benefits review.

The Revenue Cycle Specialist will work closely with insurance carriers, patients, internal billing teams, and other stakeholders to research claim issues, resolve unpaid or underpaid balances, and improve overall revenue cycle performance.

Responsibilities

• Manage the timely follow up and resolution of all outstanding accounts receivable, including unpaid, underpaid, and denied medical claims for commercial insurance, Medicare, Medicaid, and self pay accounts.
• Work assigned A/R medical collections queues and prioritize high dollar claim balances, aging accounts, and claims requiring immediate action.
• Research and resolve medical billing and insurance reimbursement issues to obtain accurate and maximum payment.
• Review incoming insurance and patient correspondence, including refund requests, claim notices, requests for documentation, and payment inquiries.
• Prepare and submit claim appeals when appropriate and provide requested medical records or supporting documentation.
• Review medical documentation and coding information to support medical necessity and claim resolution.
• Partner with medical coding and billing resources to identify claim errors, coding discrepancies, authorization issues, and other barriers to reimbursement.
• Review patient accounts and balances for accuracy and follow up with patients to obtain payment.
• Respond to incoming patient phone calls and assist with billing questions, insurance issues, payment concerns, and outstanding account balances.
• Review insurance payments and payment posting activity to determine the accuracy of reimbursement based on contracts, fee schedules, explanations of benefits, and summary plan documents.
• Use knowledge of Medicare, state Medicaid programs, and local coverage determinations to support claims analysis and resolution.
• Perform claims analyst functions by researching denials, identifying root causes, documenting actions taken, and recommending next steps.
• Negotiate payment amounts for procedures with third party administrators when supporting out of network providers.
• Recommend account adjustments when appropriate and identify overpayments that may require refunds to insurance carriers or patients.
• Maintain accurate and complete account documentation within the practice management and billing systems.
• Support insurance verification and eligibility research when needed to resolve claims or patient account issues.

Qualifications and Requirements

• At least two years of experience in ambulatory surgery center revenue cycle, orthopedic RCM, orthopedic medical billing, orthopedic collections, or a related healthcare accounts receivable role.
• Experience with medical billing, medical coding, A/R medical collections, insurance verification, payment posting, denial management, claims analysis, or accounts receivable is strongly preferred.
• Ability to read and interpret insurance explanations of benefits, managed care contracts, fee schedules, and reimbursement documentation.
• Working knowledge of commercial insurance, Medicare, Medicaid, workers’ compensation, and other healthcare payers is preferred.
• Strong written and verbal communication skills with the ability to communicate effectively with patients, insurance carriers, and internal teams.
• Ability to manage multiple priorities, maintain organized account documentation, and meet established deadlines and productivity expectations.
• Intermediate proficiency with Microsoft Office, including Excel and Outlook.
• Experience with Greenway Intergy, MedInformatix, NextGen Practice Management, or a similar medical billing or practice management system is preferred but not required.
• High school diploma or equivalent required.