Job Summary By embodying our core purpose of customer obsession, new ideas, driving innovation, and delivering excellence, you will help ensure that every touchpoint is meaningful and contributes to our mission of redefining the possible in healthcare. The Accounts Receivable Specialist shall be responsible for following up directly with commercial and governmental payers to resolve claim issues and secure appropriate and timely reimbursement. Identifies and analyzes denials and payment variances and takes action to resolve accounts, including drafting and submitting technical appeals. Job Competencies Valuing Differences - Works effectively with individuals of diverse cultures, interpersonal styles, abilities, motivations, or backgrounds; seeks out and uses unique abilities, insights, and ideas. Considers the collective. Collaboration - Works cooperatively within teams and partners with others, both internally and externally as needed, to achieve success; focuses on the results of the team, not the achievements of one person. It’s “All for One and One for All.” Accountability - Accepts personal responsibility and/or consequences of failure and successes, delivering on commitments and refocusing effort when needed. Someone willing to step up and own it. Time Management - Effectively manages personal time and resources to ensure that work is completed efficiently. Developing Trust - Gains others’ confidence by acting with integrity and following through on Commitments. Treats others and their ideas with respect and supports them in the face of challenges. Takes Initiative - Takes prompt action to accomplish goals and achieve results beyond what is required, is proactive, and pursues relentlessly. Essential Job Functions Customer Obsession - Consistently provide an exceptional experience for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas - Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence - Execute at a high level by demonstrating our “Best in KLAS” Ensemble Different principles and consistently delivering outstanding results. Examines denied and underpaid claims to determine the reason for discrepancies. Communicates directly with payers to follow up on outstanding claims, file technical appeals, resolve payment variances, and ensure timely reimbursement. Ability to identify with specific reason for underpayments, denials, and the cause of payment delay. Works with management to identify, trend, and address root causes of issues in the A/R. Maintains a thorough understanding of federal and state regulations, as well as payer-specific requirements, and takes appropriate action accordingly. Documents activity accurately, including contact names, addresses, phone numbers, and other pertinent information. Demonstrates initiative and resourcefulness by making recommendations and communicating trends and issues to management. A strong problem solver and critical thinker to resolve accounts. Must meet productivity and quality standards. Performs other duties as assigned. Education, Certifications & Experience Bachelor’s degree in any discipline 1 - 3 years of experience in medical collections, physician/hospital operations, AR Follow-up, denials & appeals, compliance, provider relations, or professional billing preferred. Good analytical skills and proficiency with MS Word, Excel, and PowerPoint. Good communication Skills (both written & verbal). Good knowledge of US healthcare, Revenue Cycle Management. The candidate should know about Medicare and Medicaid. Ability to interact positively with team members, peer groups, and seniors. Preferred Certified Revenue Cycle Representative (CRCR).
Job Summary By embodying our core purpose of customer obsession, new ideas, and driving innovation, and delivering excellence, you will help ensure that every touchpoint is meaningful and contributes to our mission of redefining the possible in healthcare. Performs documentation and coding audits for all acute inpatient services for clients. Identifies coding errors, compliance, and educational opportunities, and optimizes reimbursement by ensuring that the diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements. Performs independent reviews, interprets medical records, and applies in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns. Demonstrates high level of expertise in researching requirements necessary to make compliant recommendations. Job Competencies Valuing Differences - Works effectively with individuals of diverse cultures, interpersonal styles, abilities, motivations, or backgrounds; seeks out and uses unique abilities, insights, and ideas. Considers the collective. Collaboration - Works cooperatively within teams and partners with others, both internally and externally as needed, to achieve success; focuses on the results of the team, not the achievements of one person. It’s “All for One and One for All” Accountability - Accepts personal responsibility and/or consequences of failure and successes, delivering on commitments and refocusing effort when needed. Someone who is willing to step up and own it. Time Management - Effectively manages personal time and resources to ensure that work is completed efficiently. Developing Trust - Gains others’ confidence by acting with integrity and following through on commitments; treats others and their ideas with respect and supports them in the face of challenges. Takes Initiative - Takes prompt action to accomplish goals and achieve results beyond what is required, is proactive and pursues relentlessly. Essential Job Functions Customer Obsession - Consistently provide exceptional experience for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas - Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence - Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results. Onboarding and Training: Guiding new hires through department-specific processes, policies, and systems, including IT setup and access requests Mentorship: Supporting internal transfers and current team members through peer-to-peer education, regional or team-based sessions, and individualized coaching Documentation: Creating and maintaining SOPs, job aids, onboarding binders, and training materials tailored to departmental or client-specific needs Quality Audits: Conducting performance audits to ensure adherence to best practices, though not always responsible for delivering audit feedback Special Projects: Participating in initiatives like SWAT teams, documentation updates, and system super-user roles Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines. Ensures that the assigned DRG reflects the severity of the patient’s condition and the resources used during their hospital stay. Assesses whether the clinical documentation supports the coded diagnoses and procedures. Verifies that the medical record adequately justifies the assigned DRG. Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders. Works closely with CDI (Clinical Documentation Integrity) specialists to determine if there are documentation and/or query opportunities. Maintains productivity and quality goals as set by audit leaders. Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders, referencing current ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinics. Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations. Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines. Completes required education through internal application, compliance training and other mandatory educational requirements. Use proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately. Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided. Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions. Continues to stay informed about changes in acute inpatient coding regulations and reimbursement policies. Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns. Shares and assists in development of concepts and or process improvement, tools, etc. Education, Certifications & Experience Graduate in any discipline (B.Sc./M.Sc. Nursing, B. Pharm, M. Pharm, or Life Sciences education is preferred) Certification in Medical Billing and Coding (CPC, CCS, or equivalent) preferred. 3+ years of overall experience with 1+ years of experience in Quality Analysis within the healthcare / RCM domain. Strong understanding of end-to-end RCM processes including charge entry, payment posting, denial management, and AR follow-up. Knowledge of HIPAA and healthcare compliance standards. Proficiency in using billing software (e.g., Epic, Athena, Kareo) and QA tools. Excellent communication skills for feedback and reporting. Attention to detail with strong analytical and problem-solving skills. Ability to work independently and in a team environment.