Position Summary The Revenue Cycle Management (RCM) Specialist owns the end-to-end life of a claim — from obtaining and validating payer authorizations, through accurate claim creation and submission, to the resolution of clearinghouse rejections, payer denials, and unpaid balances. This is a full-cycle role: the Specialist is expected to work the front end (authorization, eligibility, and data integrity) and the back end (billing, denials, appeals, and A/R follow-up) rather than a single narrow function. The ideal candidate is analytical, detail-oriented, and comfortable moving between payer portals, the clearinghouse, and the billing system to find the root cause of a payment failure and fix it — not just rework it. Key Responsibilities Authorization & Eligibility • Obtain, renew, and extend prior authorizations for services and equipment prior to the date of service; track expiration dates and proactively initiate renewals before lapse. • Verify member eligibility, benefits, coverage effective/termination dates, and coordination of benefits (COB) with primary and secondary payers. • Validate that the authorization data on file — HCPCS/CPT, units, frequency, date span, diagnosis, and rendering provider — matches what will actually be billed, and correct discrepancies at the source. • May require follow-up with doctors’ offices to obtain prior authorization documentation, medical records, prescriptions, or other payer-required supporting information needed to complete authorization requests. • Escalate payer-driven or source-data authorization exceptions to the appropriate upstream team and document recurring failure patterns by payer. Claim Billing & Submission • Prepare, review, and submit clean claims (electronic and paper) to Medicare, Medicaid, managed care, commercial, and third-party payers within payer-specific timely filing windows. • Validate claim data prior to release: patient/member demographics, member and policy numbers, ICD-10 diagnosis codes, CPT/HCPCS codes, modifiers, units, place of service, NPI/taxonomy, and billing provider identifiers. • Apply payer-specific billing rules, including rental vs. purchase logic, daily vs. monthly rates, capitation and suspend arrangements, and secondary/COB billing requirements. • Perform monthly and cyclical billing runs, reconcile billed output against source records, and confirm expected claim volumes and dollar values before submission. • Process credits, rebills, corrected claims, and adjustments in accordance with policy and payer guidance. Clearinghouse Management & Rejections • Monitor clearinghouse queues daily; work front-end rejections and scrubber edits to zero before they age. • Identify systemic rejection trends and partner with billing leadership to implement edits or mapping corrections that prevent recurrence. Denials, Appeals & A/R Follow-Up • Analyze remittance advice (835/EOB) and interpret CARC adjustment codes and RARC remit remarks to determine the correct disposition: resubmit, appeal, verify eligibility, bill secondary/patient, or credit. • Work assigned denial and aging queues, prioritizing by dollar value, payer, and timely filing risk. • Compose and submit appeals and reconsiderations with supporting documentation (authorization records, medical necessity, proof of timely filing) and track them through resolution. • Distinguish recoverable denials from true contractual and non-covered write-offs, and process credits for non-recoverable lines accurately in the month of service. • Conduct soft collection follow-up and make outbound calls to payers, insurance groups, and/or subscribers to resolve outstanding balance issues, claim discrepancies, missing information, or payment delays while maintaining a professional and customer-service-focused approach. • Report denial root causes by payer, reason, and month of service, and recommend front-end fixes to reduce repeat denials. Reporting, Reconciliation & Compliance • Reconcile billing and payment data across systems; research and resolve duplicate billings, missing claims, unposted payments, and balance variances. • Maintain data integrity across operational files, including deduplication of claim numbers, validation of member numbers, and date alignment across related records. • Produce recurring and ad hoc reporting (aging, denial trending, authorization expiration, credit and adjustment summaries) with clear breakdowns by payer, reason, month of service, and location. • Maintain strict HIPAA compliance and safeguard all PHI in accordance with company policy and applicable federal and state regulations. • Support audits, month-end close, system testing/UAT, and process improvement initiatives as assigned. Required Qualifications • High school diploma or equivalent required; Associate’s or Bachelor’s degree in Healthcare Administration, Business, Finance, or a related field preferred. • 3+ years of hands-on medical billing or revenue cycle experience covering both authorization and back-end claim resolution. • Demonstrated experience with prior authorization workflows across Medicare, Medicaid, managed care, and commercial payers. • Working knowledge of CPT, HCPCS, ICD-10, modifiers, and medical terminology; ability to determine billability of a diagnosis code. • Proven ability to read and act on 835 remittances, and EOBs. • Direct experience submitting and working claims through a clearinghouse (e.g., Availity, Waystar, Change Healthcare, Office Ally, or similar), including 837/835 transactions. • Proficiency in Microsoft Excel (pivot tables, lookups, filtering large data sets) and comfort working within billing/EMR platforms and payer portals. • Strong written and verbal communication skills; able to interact professionally with payers, internal teams, and patients. Preferred Qualifications • Experience in DME, home health, remote patient monitoring, or PERS billing. • Familiarity with Bonafide, Salesforce, or comparable billing and order-management platforms. Competencies & Success Measures Success in this role is measured by clean claim rate, first-pass acceptance at the clearinghouse, denial rate and overturn rate on appeals, authorization lapse rate, days in A/R, and timely resolution of assigned work queues. • Analytical problem solving — identifies root cause rather than reworking symptoms. • Accuracy and attention to detail under high volume. • Ownership and follow-through on aged and complex accounts. • Adaptability to changing payer rules and system changes. • Collaboration across authorization, billing, cash posting, and A/R functions.