Revenue Cycle Specialist

A Lighthouse is needed to help guide the way; to emit a light that helps navigate turbulent times and warn against the possible dangers ahead. Lighthouse Behavioral Wellness Centers is just such a place, guided by its core values of hope, dedication, and community.

As a Revenue Cycle Specialist, you will participate in activities involved in the review, adjustment and collection of claims and claims denials for all Medicaid, Medicare, and Private Insurance payers.  You will assist in taking all steps necessary to ensure that claims are correct and meet billing standards for submission.  Furthermore, you will assess and monitor trends and work closely within the Revenue Cycle team environment to ensure resolution and establish best practices and workflows to prevent future errors.

To meet the increasing needs of our communities it is imperative that all team members understand and successfully reach and maintain the expected performance standard levels. In order to achieve total and sustainable success, each person must do their part. Lighthouse will do its part in providing any necessary tools and training required to help team members be successful.

DEFINITION:

Under immediate to general supervision, provides claim management for all payer claims.  This position is supervised by the Director of Revenue Cycle and Compliance.

EDUCATION AND EXPERIENCE:

High school diploma or its equivalent

Experience in the medical field, medical billing/claims, explanation of benefits, denials, or medical billing preferred.

KNOWLEDGE AND SKILLS:

Ability to develop working relationships with clinical staff and supervisors.

Must be a self-starter and able to work independently, as well, as in a team environment.

Must be very detail oriented and possess the ability to multi-task.

Proficient in utilizing Excel and Word.

JOB DUTIES AND RESPONSIBILITIES:

This position is responsible and held accountable for the following duties:

• Demonstrating a level of competence and understanding of state and federal rules and regulations regarding payer billing standards.
• Understanding billing payers and their priorities for client accounts.
• Provides support to all Revenue Cycle Team members and leadership.
• Process ODMHSAS, Medicaid, Medicare, and private insurance claims in a timely manner.
• Identify client account errors by utilizing error reports to prevent billing errors, denied claims, and missed filing. 
•  Identify client account errors that prevent billing, such as missing CDC or client setup errors, and report to direct supervisor for correction.
• Resolving payer rejections from the electronic health record (EHR) prior to billing submission.
• Perform Medicare and private insurance corrections to claims and resubmit to payer.
• Correct denied OHCA and ODMHSAS claims and resubmit through OHCA portal.
• Appeal claims when appropriate according to payer rules.
• Research payments and posts non-electronic EOB’s to accounts timely to accurately reflect monies received.
• Review, work and document private insurance and Medicare coverage verification daily and report any discrepancies to direct supervisor for review.
• Reporting error trends, claims denial trends, and contract billing issues to the Director of Revenue Cycle and Compliance weekly.
• Assists Director of Revenue Cycle and Compliance, and Accounting with the reconciliation of accounts.
• Reviews client accounts prior to appointment communicating CDC or prior authorization needs to clinic Navigators, Clinicians, and Leadership as needed.
• Review Crisis accounts, both current admissions and recently discharged, to ensure accuracy in CDC or prior authorization to ensure claim submission success.
• Verify ODMHSAS, Medicare, Medicaid, and private insurance coverage requirements and work to ensure that all services have the necessary approvals in place prior to bill generation.
• Review and correct CDC and prior authorization errors prior to billing submission.
• Act as liaison between Lighthouse and the ODMHSAS helpdesk to correct or backdate CDC’s.
• Work OneDesk tickets to address CDC issues.
• Review and analyze denied, rejected, or underpaid claims, identifying reasons for non-payment (e.g., coding errors, authorization issues, payer policy denials).
• Work proactively to resolve denials by re-submitting corrected claims, initiating appeals, and collaborating with insurance providers for payment resolution.
• Identify patterns in denials and report to Director of Revenue Cycle and Compliance in a timely manner.
• Prepare and submit timely and accurate appeal documentation for claims that have been denied or underpaid, ensuring all required information is included (e.g., medical records, patient history, corrected codes).
• Follow up on appeals to ensure timely resolution and to track the status of each claim.
• Maintain detailed records of all denial and appeal activity, including correspondence with insurance payers and any necessary corrective actions.
• Conduct regular audits and analysis of denied claims to identify trends or recurring issues.
• Generate and present reports to management outlining denial rates, reasons for denials, and potential strategies to reduce future denials.
• Adheres to Lighthouse policies and procedures.
• Regular and predictable attendance is an essential job requirement.
• Must be willing and able to perform all job-related travel normally associated with this position.
• Must meet “satisfactory” expectations at any scheduled job performance evaluation, coaching and/or Performance Improvement Plans.
• Must complete Lighthouse required training and resulting follow up and consultation as required at hire, annually and as directed by Supervisor.
• Performs other reasonably related duties as assigned by the immediate supervisor or other management as requested.
• Assists with completing special assignments and necessary.
• In addition, must possess skill in working cooperatively and effectively with clients, staff, management and other professional and community groups; in exercising mature judgment in dealing with people; in presenting ideas clearly and accurately; in reading and comprehending the English language; and in communicating effectively, both orally and in writing.

BENEFITS:

Benefits include: 100% employer-paid premiums for health, dental, life, and vision insurance; generous paid leave including PTO, sick, and agency holidays, employer matching 401K plan, and paid continuing education.

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Professional development assistance
• Vision insurance

Job Type:

• Full-time

Schedule:

• 8-hour shift
• Day shift
• Monday to Friday

Ability to commute/relocate:

• Ardmore, OK: Reliably commute or planning to relocate before starting work (Preferred)

Work Location:

• One location