Specialist, RCM

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.