At Houston Methodist, the Revenue Cycle Specialist is responsible for providing direct and indirect revenue cycle support to the Revenue Cycle Managers. It is responsible for the timely coordination and completion of regulatory and/or revenue-enhancing special projects as identified by the Revenue Cycle Managers. In addition, the Revenue Cycle Specialist is responsible for resolving all outstanding third-party primary and secondary insurance claims for professional services. This Specialist is required to perform collections activities on complex denials and prepare complex appeals on outstanding insurance balances in the professional fee environment. This role is also responsible servicing as the subject matter expert in account follow-up. Also is responsible for providing information regarding complex denial trends for future prevention. The individual who holds this position exemplifies the mission, vision and values and acts in accordance with all HMH and PO CBO policies and procedures, including complying with The Houston Methodist Experience Service Standards.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience.

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Displays cultural humility, diversity, equity and inclusion principles

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

PEOPLE ESSENTIAL FUNCTIONS

• Collaborates with management to target complex claims and reduce aging of accounts by providing verbal and written communication.

• Assists with knowledge sharing, training payor and department cross training, and provides support to other team members as advised by the Manager and/or Supervisor.

• Identifies denial trends and notifies Supervisor and/or Manager to prevent future denials and further delay in payments. Collaborates with internal CBO departments and Account Managers to communicate and prevent denials. Provides suggestions for resolution.

SERVICE ESSENTIAL FUNCTIONS

• Completes special projects to improve team performance, as assigned.

• Demonstrates expertise and serves as the subject matter expert with all payers, including Medicare, Medicaid and commercial payers, and applicable department's revenue cycle operations. Provides coaching and support to projects related to collection efforts.

• Ensures protection of private health and personal information. Adheres to all HIPAA and PCI compliance regulations.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Reviews third party payer work queues for complex payers and resolve accounts.

• Manages denials and appeals efforts. Creates and submits appeals when necessary.

• Resolves denials as they appear with actionable items that result in resolution. Engages the coding follow up team for any medical necessity or coding related appeals.

• Assures accounts are completed and worked at a high level of quality by visually proofreading and monitoring work output. Documents clear, concise and complete follow up notes in system for each account worked.

• Identifies, analyzes and escalates trends impacting AR collections.

FINANCE ESSENTIAL FUNCTIONS

• Expedites and maximizes payment of insurance medical claims by contacting third party payers and patients. This includes making outbound calls to payers and accessing payer websites.

• Reviews and assesses entire account to determine necessary steps or activity to resolve outstanding denials.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Remains current on collection procedures of various payors and specialty departments.

• Assists with knowledge sharing, payor and department training, and provide support to other team members as advised by the manager and/or supervisor.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)

• Assoicates Degree preferred

WORK EXPERIENCE

• Minimum five years' experience in commercial insurance follow-up

LICENSES AND CERTIFICATIONS - REQUIRED

• N/A

LICENSES AND CERTIFICATIONS - PREFERRED

• CRCP - Certified Revenue Cycle Professional (AAHAM) -- Technician

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Understands payor plan policies and environment for government, managed care, IPAs, and TPAs

• Exercises good judgment in handling of accounts and demonstrates a professional approach in dealing with patients and insurance companies.

• Understanding of insurance contractual agreements, payer policies, guidelines and appeals process.

• Sharp analytical abilities are required in order to resolve the patient accounts in a timely and accurate manner.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No

Houston Methodist Specialty Physician Group - As one of the nation’s leading hospitals and academic medical centers Houston Methodist has brought together some of the nation’s leading experts in multiple specialties to serve our patients.  As part of Houston Methodist Specialty Physician Group (HMSPG), these specialists not only provide excellent clinical care, but are on the forefront of research, developing leading-edge technologies and treatments, and teaching the medical pioneers of tomorrow.  This combination of clinical service, research and academics ensures patients have access to the latest in treatments and technologies while providing the best in comprehensive patient care.  Established as a non-profit corporation and certified by the Texas State Board of Medical Examiners, HMSPG enables physicians to maintain autonomy with respect to their clinical practice while growing their practice within an academic environment.