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Core Responsibilities

Revenue Cycle Trend Analysis & Oversight

· Monitor and analyze revenue cycle performance metrics to identify trends causing claim delays, clearinghouse rejections, denials, underpayments, delayed payments, aging AR, or reimbursement slowdowns.

· Identify recurring issues across departments, payers, CPT codes, diagnosis coding, providers, facilities, or workflow stages.

· Conduct root cause analysis on both pre-submission and post-submission claim issues impacting clean claim rates, turnaround times, denial rates, reimbursement recovery, and cash collections.

· Track trends related to eligibility, prior authorizations, coding accuracy, documentation gaps, modifier usage, payer edits, clearinghouse rejections, denial codes, remittance data, payer correspondence, EOBs/ERAs, and payer behaviors.

Claim Scrubbing, Coding Review & Pre-Submission Operations

· Review and scrub claims prior to submission to ensure all patient, provider, CPT, HCPCS, modifier, and diagnosis information is accurate and complete.

· Validate CPT and ICD-10 coding for medical necessity and payer compliance in accordance with CMS, LCD/NCD, and commercial payer guidelines.

· Identify claim discrepancies, missing documentation, eligibility issues, authorization gaps, coding concerns, or workflow failures and coordinate resolution efforts with internal and external stakeholders.

· Partner with operational and clinical teams to reduce avoidable front-end errors and improve clean claim submission rates.

Denial Management, Appeals & Revenue Recovery

· Monitor submitted claims and accounts receivable to identify trends related to denials, delayed payments, underpayments, aging AR, and reimbursement slowdowns.

· Analyze denial codes, remittance data, payer correspondence, and EOBs/ERAs to determine root causes, financial impact, and recovery opportunities.

· Track appeals, reconsiderations, corrected claims, and escalation workflow success to maximize reimbursement recovery.

· Identify and trend payer behaviors including medical necessity denials, authorization issues, coding discrepancies, bundling edits, frequency limitations, documentation requests, and payer-specific billing requirements.

AR Follow-Up & Post-Submission Operations

· Perform detailed AR follow-up activities to ensure timely payer responses, appropriate claim resolution, and reduction of outstanding balances.

· Communicate directly with payers, clearinghouses, and internal teams regarding claim status, billing discrepancies, documentation requests, and reimbursement delays.

· Maintain accurate documentation, payer notes, appeal tracking, and follow-up logs within billing and RCM systems.

· Ensure unresolved claims are escalated appropriately based on aging, financial impact, payer responsiveness, or operational risk.

Corrective Action & Process Improvement

· Present findings, trends, root cause analysis, recovery opportunities, and operational recommendations to the RCM Director, RCM Managers, and leadership team on a consistent basis.

· Assist with implementing approved process improvements into existing departmental workflows and SOPs.

· Work collaboratively with operational, billing, clinical, and leadership teams to ensure corrective actions are adopted, maintained, and measured over time.

· Monitor the effectiveness of implemented workflow changes and measure resulting performance improvements across clean claim rates, denial reduction, AR recovery, DSO, and cash collections.

· Other duties as assigned

Reporting & Operational Insights

Prepare weekly and monthly reporting for the RCM Director and RCM Managers outlining key operational and financial insights, including:

· Key reimbursement trends and denial trends

· Root cause findings and high-impact denial categories

· AR aging performance, recovery rates, and appeal outcomes

· High-impact payer issues and reimbursement barriers

· Workflow inefficiencies and operational bottlenecks

· Recommended corrective actions and status updates on implemented improvements

· Opportunities to reduce DSO and improve cash collections

Qualifications

· 2+ years of experience in Revenue Cycle Management, medical billing, claims analysis, coding, denial management, or AR follow-up; laboratory or diagnostic experience strongly preferred.

· Strong understanding of CPT, ICD-10, HCPCS, modifiers, EOB/ERA interpretation, payer appeals, reimbursement recovery, and payer billing requirements.

· Experience analyzing denials, reimbursement trends, AR aging, claim acceptance issues, and operational workflow inefficiencies.

· Familiarity with claim scrubbing software, EHRs, billing software, clearinghouses, payer portals, laboratory billing workflows, and RCM reporting dashboards.

· Working knowledge of CMS regulations, LCD/NCD policies, prior authorization workflows, commercial payer billing rules, medical necessity requirements, and payer-specific reimbursement guidelines.

· Experience collaborating across multiple operational, billing, clinical, and leadership teams.

· CPC, COC, CRCR, or equivalent certification preferred but not required.

Personal Skills

· Strong analytical and problem-solving mindset with the ability to identify reimbursement trends, operational patterns, and process improvement opportunities.

· Highly detail-oriented with strong organizational, documentation, and follow-through capabilities.

· Excellent written, verbal, and interpersonal communication skills, including payer correspondence and escalation communication.

· Ability to manage multiple priorities and drive measurable process improvements in a fast-paced environment.

· Self-motivated, proactive, persistent, resourceful, and solution-oriented.

· Comfortable working independently while collaborating across departments and leadership teams.