Summary of Major Responsibilities

The Revenue Cycle System Specialist assists to build/maintain/correct systematic issues to ensure timely and accurate processing of claims, appeals, denials, and statements for Exact Sciences. A Systems Specialist demonstrates proven medical insurance knowledge by analytically identifying and resolving billing discrepancies regarding eligibility, denials, appeals, and aged unpaid claim follow up for commercial, government, and plan coverage for optimal Account Receivable (AR) outcomes. A Revenue Cycle Systems Specialist effectively strategizes solutions and effectively communicates resolutions to build to ancillary departments and ensures appropriate coverage mapping by utilizing Epic, external portals, and other software.

Essential Duties and Responsibilities

• Able to resolve high complexity revenue cycle problems including but not limited to missing documentation, remittance issues, and special handling per payor requirements.
• Able to identify root cause issues with billing, coding, and reimbursement as well as communicating issues to appropriate members of revenue cycle leadership and helping to identify potential solutions.
• Take an active role in process improvement initiatives related to revenue cycle functions in collaboration with the revenue cycle leadership team.
• Independently determine initial or ongoing patient insurance eligibility verification issues, investigate and correct accounts within Epic including updates to patient demographics, financial information, and guarantor information.
• Able to interact with various insurances/third party billers/clearing houses accurately and timely to identify and resolve systematic issues.
• Maintain strictest confidentiality; adheres to all HIPAA guidelines and regulations.
• Review/edit/troubleshoot claim edits and appeals prior to submitting to claim scrubber/clearing house.
• Analyze, research, and resolve claim issues applying to federal, state, and payor rules and procedures with a high degree of independence.
• Understand explanation of payments and analyze and complete appropriate steps for all denials by appropriately identifying claim resolutions next steps including appealing, writing off, or sending statements.
• Work cross functionally with Accounts Receivable specialists and Market Access Manager teams to analyzes denial and rejection trends and identify and communicate root cause issues and recommendation for systematic or process changes to reduce future denials/rejections.
• Participate in regularly scheduled team meetings, sharing current issues and trends by payor, rejection, or denials to collaborate on process or systematic enhancements.
• Understand all Revenue Cycle workflows to allow for ad hoc support as necessary within the department (i.e. special projects, provide support due to outages/high volume).
• Complete position responsibilities within the appropriate time frame while adhering to quality standards.
• Demonstrate excellent problem-solving abilities and organizational skills.
• Able to work in a team environment and adapt to changing workload and circumstances effectively able to respond to new information quickly.
• Disciplined, self-motivated & reliable; ability to stay focused on a task and work independently; ability to handle pressure of deadlines and complex issues; motivated to perform quality work; diligent about arriving to work on time and completing tasks that are assigned in a timely manner.
• Support and collaborate to maintain most current system knowledge bases while ensuring timely updates are made to the respective systems and resolve systematic issues.
• Build and maintain payor contracts in Epic.
• Monitor error reports and resolve issues that relate to billing file maintenance; including, but not limited to, payor interface errors, system related error messages, and manual pricing releases.
• Report and suggest file maintenance changes to Revenue Cycle Leadership and Revenue Cycle staff, as needed.
• Good written and verbal English communication skills; ability to professionally communicate with all customers and vendor partners.
• Good analytical skills and critical thinking abilities.
• Ability to work independently.
• Ensure compliance with all Company procedures and guidelines; including, but not limited to, Code of Business Conduct and Ethics.
• Uphold company mission and values through accountability, innovation, integrity, quality, and teamwork.
• Support and comply with the company's Quality Management System policies and procedures.
• Regular and reliable attendance.
• Ability to work overtime as needed.
• Ability to work on a mobile device, tablet, or in front of a computer screen and/or perform typing for approximately 90% of a typical working day.
• Ability to work on a computer and phone simultaneously.
• You will be required to successfully complete and pass exam for Resolute Professional Billing Expected Reimbursement Contracts Epic Verona training course within the first 6 months of hire. Exact Sciences will make a reasonable accommodation available, if necessary, to assist an employee with a disability to satisfy this requirement.

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Qualifications

Minimum Qualifications

• High School Diploma or General Education Degree (GED).
• 2+ years of experience in EMR/Revenue Cycle systems.
• Demonstrated working knowledge of third-party billing.
• Demonstrated ability to identify payor payment inconsistencies or other issues proactively; to comprehend billing ledgers of charges, payments, and adjustments.
• Strong understanding of governmental, managed care, and commercial insurances, claim submission requirements, reimbursement guidelines and denial reason codes.
• Proficient computer skills to include Internet navigation, Email usage, and word processing.
• Proficient in Microsoft Office.
• Demonstrated ability to perform the Essential Duties of the position with or without accommodation.
• Authorization to work in the United States without sponsorship.

Preferred Qualifications

• Some college course work.
• 2+ years of experience in Epic Resolute PB.

We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to age, color, creed, disability, gender identity, national origin, protected veteran status, race, religion, sex, sexual orientation, and any other status protected by applicable local, state or federal law. Applicable portions of the Company's affirmative action program are available to any applicant or employee for inspection upon request.