Job Summary

The Patient Health Revenue Cycle Specialist II works to ensure an efficient revenue cycle as related to claims and encounters, including claims submission, coding corrections, third-party payer payment posting, denial management, and account receivables follow-up. The Specialist provides support on projects involving provider enrollment, contracting, claim submissions, audits, billing corrections, A/R, rectifying patient account issues, and correcting internal errors. Under limited supervision, working within the departmental scope and with advanced knowledge of various Whitman-Walker departmental policies and procedures, works to identify, address, and resolve claim issues and/or questions that are escalated to the team, the Specialist performs a range of tasks promptly, accurately and consistently ensure strong billing operations, also works collaboratively with the appropriate internal department(s) and external entities to enhance revenue cycle performance and identify opportunities for process improvement, increase and maximize health care revenue for billable claims.

Role Specific Primary Essential Duties:

* Demonstrates initiative in performing tasks to support strong billing cycle processes and EHR functionality to ensure maximum reimbursement of billable claims.

* Works independently while helping identify possible areas of concern in the revenue cycle process to determine workflow deficiencies and root causes.

* Identifies and reports on internal and external issues that impact claims processing and submissions to improve timely collections, accurate payment posting, denial management, and other trends to improve revenue cycle processes.

* Maintains data integrity when manipulating data files for purposes of analysis to ensure data does not become corrupted through conscientious use of tools, a system of checks and balances, and organizational statistical knowledge.

* Proactively monitors denial management process and identifies gaps.

* Accurately and consistently performs appropriate tasks to ensure the accuracy of patient accounts and address inquiries and correspondence, including but not limited to verification of insurance coverage and benefits, payment posting, and working denials and/or rejection of reimbursable claims.

* Timely and accurately supports and resolves issues affecting revenue and investigates unpaid claims to resolve any issues and secure payment, including but not limited to providing guidance and support to providers/ clinicians of required, missing, invalid, or incomplete documentation.

* Works to ensure all tasks are performed in compliance with FQHC billing policies and guidelines established by Medicare, Medicaid, and other federal and local regulations, rules, laws, and contractual requirements.

* Ensures claims-related correspondence, tracking deadlines, responding to requests, and assisting other departments and external contacts, as needed, and in support of billing operations.

* Proactively research and report on accounts to determine the root cause of open receivables and determine and execute the best approach for rebilling and timely and accurate resolution.

* Establishes and maintains professional and effective relationships with peers, payors, patients, and other stakeholders; Serves as liaison with various internal departments/ staff/providers in coordinating and troubleshooting various revenue cycle-related issues.

* Utilizes internal and payor technology and resources to support account resolution activities.

* Provides limited support to assist appropriate staff with access issues on provider portals. Upholds Whitman-Walker standards and practices by adhering to HIPAA and other confidentiality requirements.

* Strong knowledge of and adherence to all VWH policies and procedures.

* Takes initiative and finds continued education opportunities for personal and departmental development.

* Works with manager in identifying, researching, and resolving issues that may have led to inaccurate or untimely filing of claims, claim rejections, and/or other billing and collections issues.

* Proactively assists the manager in providing training, assistance, and/or guidance to other staff members regarding issues pertaining to account resolution through billing, collections, and/or denial processing techniques.

* Staff the billing phone line to address patient inquiries and staff inquiries for billing questions and questions about balances. Service will be provided professionally, promptly, and accurately. Promptly checks voicemail and billing email inbox and responds immediately or within 48 hours or less.

* Strong understanding of credentialing and privileging practices and their direct impact on operational and financial impact.

* Compiles and maintains current and accurate data for all providers and provider types including Credentialing Matrix, rosters, log-on credentials, portal access, and any other information required to effectively enroll, monitor, update, and report on credentialing/enrollment status and files.

* Completes assigned provider credentialing and re-credentialing applications; monitors applications and follows up promptly to ensure revenue maximization.

* Maintains information in the database, including but not limited to PECOS, CAQH, ePREP, NPPES, etc., that is essential for enduring accurate and current credentialing and contracting files.

* Works with other departments to ensure that copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all billable providers Maintains corporate provider contract files related to contracting and credentialing.

* Advanced knowledge of current health plan and agency requirements for credentialing providers and facility contracts/enrollment.

* Notifies appropriate internal and external parties of credentialing approvals or issues that have a direct or indirect impact on revenue/collections.

* Responsible for providing patient statements upon request.

* Sorts, handles, and files incoming billing-related correspondence.

* Other duties assigned

Role Specific- Knowledge, Skills, and Talents Required:

* Strong knowledge of third-party billing and reimbursement practices, policies, and procedures.

* Excellent customer service and computer skills required, with attention to detail and the ability to work both independently and cooperatively with team members.

* Excellent oral and written communication skills, including the ability to build relationships with internal and external clients.

* Communicates effectively and consistently with strong knowledge of the organization to external vendors/payor to assist with site visits, audits, and other contractual requirements. Proficiency in Microsoft Office Suite required; additional proficiency and/or experience with electronic medical record program required.

* Advanced familiarity with provider credentialing, pre-authorization, and referrals in an FQHC setting.

* Strong knowledge of insurance eligibility and coverage experience, including navigating websites for online benefits and coverage review.

* Establishes and maintains effective working relationships internally and externally.

* Strong ability to advance multiple priorities.

Education and Experience Required:

* Associate's degree or equivalent work experience required.

* 6 years of experience of relevant experience in a high-volume healthcare billing or revenue cycle setting for FQHC.

* Intermediate level Excel skills with the ability to do Al (Storing and Presenting Data) level II Excel tasks: PIVOTs, Sum, Count, Avg functions; charts with Secondary Axis or Multiple Chart Types.

* Strong knowledge of billing and operations policies and procedures, payor billing guidelines of billable and non-billable encounters for all service areas, workflows, and processes.

* AAHAM Certified Revenue Cycle Specialist (CRCS-1/CRCS-P) Certification or NAMSS Certified Provider Credentialing Specialist (CPCS) preferred.

* Experience working with a broadly diverse population and the ability to work harmoniously with diverse groups of individuals are required.

* Experience working with members of the Lesbian, Gay, Bisexual, Transgender, Gender Expansive, Queer, Asexual, and Intersexed communities preferred.

* Experience working with people living with HIV or issues related to HIV care preferred.