Revenue Cycle Specialist

The Providence Community Health Centers, Inc.•Warwick, RI

About The Position

The Revenue Cycle Specialist manages the financial aspects of patient care by accurately coding diagnoses and treatments, submitting claims to insurance companies, addressing billing inquiries, resolving payment denials, and ensuring timely and accurate reimbursement while meeting department productivity and quality requirements. The role reviews clinical documentation and billing work queues, verifies information needed for clean claims, and uses electronic health record and billing systems to manage patient and claim data. It monitors claims and payment activity, resolves denials and discrepancies, posts and reconciles payments, manages credits and refunds, and maintains remittance records for auditing. The specialist communicates with patients, payers, providers, and health center staff while maintaining confidentiality and compliance with applicable billing and privacy requirements. The position requires a high school diploma or equivalent and two to three years of experience in medical billing, payment posting, or healthcare finance. Certified Professional Coder certification and Spanish fluency are preferred but not required. The work environment has a usually moderate noise level, and the role is classified by the CDC as Low Risk for occupational exposure.

Requirements

High school diploma or equivalent.
Two to three years of experience as a medical biller, in payment posting, or in healthcare finance.
Proficiency in medical terminology and working knowledge of CPT, HCPCS, modifiers, and ICD-10 coding.
Experience with the EPIC Electronic Health Record, Professional Billing System, and web-based applications and websites.
Working knowledge of resolving unpaid or denied claims to ensure timely payment.
Experience with electronic or clearinghouse billing software and ability to identify and resolve, or collaborate with management to resolve, claim formatting issues.
Knowledge of federal payer regulations, third-party payers, HIPAA rules, reimbursement policies, and procedures, with the ability to interpret and apply guidelines.
Strong multitasking skills and consistent attention to detail.
Effective interpersonal, verbal, and written communication skills, including the ability to collaborate with team members to resolve questions about assignments.
Knowledge of HIPAA regulations.
Excellent computer skills, including Microsoft Word, Excel, and Outlook.
Ability to read, comprehend, and apply standard operating procedures and present information by telephone and in one-on-one situations.
Ability to perform basic arithmetic using whole numbers and apply common-sense understanding to written or oral instructions and problems involving several variables in standardized situations.
Ability to explain information accurately and tactfully, remain professional in stressful situations, recognize names, detect and avoid scheduling and message-taking errors, work courteously with others, and exercise patience.
Ability to sit regularly; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. Occasional standing, balancing, and stooping are required.
Ability to regularly lift and/or move up to 10 pounds; required vision abilities include close, distance, and color vision and the ability to adjust focus.

Nice To Haves

Certified Professional Coder certification, preferably through AAPC; preferred but not required.
Fluency in Spanish; preferred but not required.

Responsibilities

Maintain HIPAA standards, protect patient confidentiality, and uphold a strong code of ethics.
Review clinical documentation and charge-review edits to confirm diagnostic and procedural codes and modifiers, resolve edits, and perform manual charge entry for hospital-related services when needed.
Verify the information needed for clean claims, including provider, place of service, date of service, bill area, codes, and payer-, contract-, or PCHC-defined billing procedures.
Use EHR and billing software to enter, update, and manage patient demographic information, insurance details, and billing records accurately and securely.
Monitor medical and dental claim status, identify and resolve denials, rejections, unpaid claims, and billing issues, and follow up with payers to support timely reimbursement.
Respond to billing inquiries from patients, insurance companies, and healthcare providers; research claim status and resolve discrepancies.
Maintain current knowledge of healthcare billing regulations, coding guidelines, and payer policies, and comply with HIPAA, CMS, and other applicable requirements.
Post insurance and patient payments and adjustments, reconcile encounters against billed amounts, address discrepancies, and interpret EOB information to record payment and denial codes.
Maintain a complete online PDF file of remittance advice for auditing purposes.
Research and post unidentified or unapplied payments, including self-pay credit balances.
Review and resolve outstanding credits, correct over-posted encounters, and refund applicable true overpayments made by patients or insurance carriers.
Document trends and issues that cause claim edits, incorrect posting, or payment denials, and report them to management for resolution.
Communicate professionally and collaborate with providers, nurses, health center staff, coworkers, patients, and payers.
Maintain accurate and organized billing records and notes; bill patients for outstanding balances and copays and work with patients on reasonable payment plans.