Revenue Cycle Specialist

Omaha Tribe of Nebraska•Macy, NE

About The Position

The Revenue Cycle Specialist researches, corrects, resubmits, and resolves medical claims that are 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 to resolution. It 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 services provided by the Health Center. The position monitors electronic clearinghouse rejections, researches and corrects claim issues, and submits corrected claims, resubmissions, reconsiderations, and appeals as appropriate. It investigates complex and recurring denials; follows up on unpaid, pending, underpaid, or incorrectly processed claims; and addresses claim payment issues related to prior authorizations. The specialist tracks actions, deadlines, payer responses, and outcomes, escalating issues when necessary. The role maintains accurate claim and payer communication records, identifies opportunities to improve claim resolution, and assists with billing reviews, payer audits, and quality improvement activities. It protects patient confidentiality, complies with applicable privacy and security laws and Health Center policies, and performs other related duties assigned by the Business Office Manager.

Requirements

An 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.
Ability to research and resolve claim rejections, denials, and billing discrepancies and to learn payer-specific correction, resubmission, reconsideration, and appeal requirements.
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 designated electronic clearinghouse for rejected claims, submission errors, and other claim transmission issues; research, correct, resubmit, document, and track rejections through resolution.
Review remittance advice, explanations of benefits, denial reports, and claim status information to identify denied or incorrectly processed claims.
Research denial reasons and payer requirements; correct claim information, coordinate documentation or coding clarification, and prepare corrected claims, resubmissions, reconsiderations, or appeals as appropriate.
Track corrected claims and appeals, document payer responses and outcomes, and escalate claims requiring management review, clinical clarification, or additional intervention.
Investigate recurring and complex denials to identify root causes and report significant denial trends to the Business Office Manager.
Research unpaid, pending, underpaid, and incorrectly processed claims; follow up with payers and determine whether correction, resubmission, documentation, reconsideration, or appeal is appropriate.
Monitor claims approaching timely filing limits, appeal deadlines, and other payer-specific timeframes; maintain a tracking system and follow up until claims are resolved, escalated, or closed with documented justification.
Research denials related to missing, incomplete, expired, or mismatched prior authorizations; coordinate with responsible staff, monitor corrected claims, document actions, and escalate unresolved issues.
Maintain accurate records of rejections, denials, corrected claims, appeals, payer communications, and resolution efforts, including 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, claim correction procedures, appeal requirements, and billing guidelines.
Protect patient confidentiality and health record security; 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.