Revenue Cycle Specialist

Omaha Tribe of Nebraska•Macy, NE

4d•$20 - $23

About The Position

The Revenue Cycle Specialist researches, corrects, resubmits, and resolves medical claims rejected, denied, underpaid, or otherwise processed incorrectly by insurance payers. The role identifies causes of claim issues, coordinates corrections with internal departments and external payers, and follows claims through resolution. The position works closely with the Billing Technician, Business Office Manager, providers, coding staff, clinical departments, and insurance representatives to resolve billing issues, reduce preventable denials, and support appropriate reimbursement for Health Center services. The specialist monitors electronic clearinghouse rejections; reviews denial and payment information; researches claim issues and payer requirements; prepares corrected claims, reconsiderations, and appeals; and follows up on unpaid, pending, underpaid, or incorrectly processed claims. The role also addresses authorization-related claim problems, maintains detailed records and follow-up plans, identifies recurring issues, and assists with billing reviews, payer audits, and quality improvement activities. Routine prior authorization requests remain with designated staff unless otherwise assigned. The position requires protecting patient confidentiality and complying with applicable privacy and security laws, payer requirements, and Health Center policies. Other related duties may be assigned by the Business Office Manager.

Requirements

Associate of Arts (AA) degree or at least two years of relevant work experience in medical billing, healthcare administration, insurance claims processing, accounts receivable, or a related field.
Ability to research billing issues, identify errors, follow established procedures, and complete corrective actions accurately and promptly.
Strong attention to detail and ability to organize work, meet deadlines, maintain accurate documentation, and communicate effectively with internal departments and insurance payers.
Ability to learn and apply insurance payer requirements, claim correction procedures, and denial resolution processes.
Experience reviewing electronic clearinghouse rejections, insurance denials, and payment discrepancies.
Experience correcting and resubmitting claims, researching unpaid claims, or assisting with appeals and reconsiderations.
Strong organizational, analytical, and problem-solving skills.
Effective written and verbal communication skills.
Ability to recognize recurring billing issues and communicate potential solutions.
Ability to maintain accurate records and protect confidential patient information.
Proficiency with standard computer applications, including Microsoft Word and Excel, and ability to learn designated billing systems and electronic clearinghouse tools.
Ability to work independently, manage competing priorities, meet deadlines, and seek assistance when necessary.
Ability to coordinate professionally with internal departments and external insurance representatives.

Nice To Haves

Familiarity with electronic clearinghouses, payer portals, electronic health records, or practice management systems.
Knowledge of Medicare, Medicaid, commercial insurance, managed care plans, and payer billing requirements.
Familiarity with ICD-10-CM, CPT, and HCPCS coding concepts.
Medical billing certification, such as Certified Professional Biller (CPB), or medical coding certification, such as Certified Professional Coder (CPC); certification is preferred but not required.
Experience working in a Tribal Health, Indian Health Service (IHS), community health center, or similar healthcare setting.

Responsibilities

Monitor the electronic clearinghouse for rejected claims, submission errors, and transmission issues; research rejections, take corrective action, coordinate with relevant staff, and track unresolved items through resolution.
Review remittance advice, explanations of benefits, denial reports, and claim status information to identify denied or incorrectly processed claims.
Research denial reasons, payer requirements, claim history, and supporting documentation; correct claim information and coordinate documentation or coding clarification.
Prepare and submit corrected claims, resubmissions, reconsiderations, and appeals as appropriate, then track payer receipt and processing.
Investigate recurring and complex denials, research relevant payer policies and requirements, contact insurance representatives, and coordinate with providers, coding staff, and clinical departments.
Monitor appealed claims until a determination is received and report significant recurring denial trends to the Business Office Manager.
Research unpaid, pending, underpaid, and incorrectly processed claims; follow up with payers and assess whether correction, resubmission, documentation, reconsideration, or appeal is appropriate.
Monitor timely filing limits, appeal deadlines, and other payer timeframes; maintain claim tracking records and follow up until resolution, escalation, or documented closure.
Research authorization-related claim denials, coordinate with appropriate staff to obtain authorization information or documentation, and monitor corrected claims.
Maintain accurate records of rejections, denials, corrected claims, appeals, payer communications, actions, next steps, and follow-up dates.
Coordinate with the Billing Technician and other departments to address recurring claim issues and identify opportunities to reduce preventable rejections and denials.
Assist with billing reviews, payer audits, and quality improvement activities as assigned; maintain knowledge of payer policies and billing guidelines.
Protect confidential patient information and comply with applicable privacy and security laws, payer requirements, and Health Center procedures.
Perform other related duties within the scope of the position as assigned by the Business Office Manager.