RCM Specialist

Job Description Job title: RCM Specialist - Out of Network (OON) Department: Revenue Cycle Reports to: Revenue Cycle Supervisor General Summary: The Out of Network (OON) Benefits and Revenue Cycle Management (RCM) Specialist is a key member of the revenue cycle team, responsible for ensuring the smooth and efficient management of OON claims and patient financial processes. This role involves verifying OON benefits, obtaining prior authorizations, coordinating surgical scheduling, and effectively communicating cost-sharing and out-of-pocket obligations with patients. The specialist will manage claims payments, appeal denials, and negotiate reimbursements while maintaining compliance with regulations such as the No Surprises Act. With strong analytical, communication, and problem-solving skills, the ideal candidate will identify opportunities for process improvement and uphold a high standard of customer service to enhance the overall patient and provider experience. Responsibilities: Benefit Verification and Prior Authorizations Verify OON benefits for patients, ensuring accuracy and thorough understanding of coverage details. Obtain prior authorizations from insurance companies in a timely manner. Patient Coordination and Communication Collaborate with practice staff to schedule patients' surgeries, ensuring all logistics are addressed. Communicate with patients regarding cost-sharing details, out-of-pocket obligations, and financial options. Claims Management and Denial Resolution Follow up on outstanding claims payments to ensure timely and accurate reimbursements. Assist in appealing denied claims and resolving issues with insurance carriers. Negotiations and Compliance Negotiate payments for OON claims and work with pricing networks. Ensure compliance with the No Surprises Act and manage arbitration processes as needed. Customer Service and Stakeholder Engagement Provide excellent customer service to patients and collaborate effectively with staff and insurance carriers. Address billing inquiries and assist in resolving issues efficiently. Trend Analysis and Improvement Opportunities Analyze billing data to identify trends, risks, and opportunities for improvement in revenue cycle processes. Qualifications and Experience: Minimum of 5 years of experience in healthcare revenue cycle management or medical billing. Hands-on experience with OON claims, pricing networks, and claim appeals. Exceptional negotiation skills, particularly for OON claims. Strong understanding of the No Surprises Act, arbitration processes, and payer guidelines. Excellent verbal and written communication skills. Strong organizational skills, with the ability to manage priorities and workflows. Advanced problem-solving and decision-making skills. Familiarity with ICD-10 and CPT procedural coding. #J-18808-Ljbffr

Created: 2025-02-05