Role Category: Healthcare Revenue Cycle

Overview:
Manages outstanding patient and insurance account balances to ensure timely collection of revenue for healthcare services provided.

Core Responsibilities:

• Monitor aging reports and follow up on unpaid insurance and patient balances.
• Investigate claim denials, payment discrepancies, and appeal processes.
• Communicate with payers, patients, and internal teams to resolve AR issues.
• Post payments, adjustments, and reconcile accounts as needed.
• Maintain documentation of collection activities and outcomes.
• Support financial reporting related to collections, cash flow, and revenue trends. 

Overview:
Serves as the first point of contact for patients, handling registration, insurance verification, and appointment scheduling to ensure seamless access to care.

Core Responsibilities:

• Register patients and collect demographic, insurance, and financial information.
• Verify insurance coverage and obtain pre-authorizations when required.
• Schedule appointments, admissions, or procedures accurately.
• Educate patients on financial responsibilities, co-pays, and payment options.
• Maintain patient privacy and data confidentiality in compliance with HIPAA.
• Provide excellent customer service to patients, families, and clinical staff.

Overview:
Assigns appropriate medical codes to diagnoses, procedures, and services for accurate billing, reimbursement, and data reporting.

Core Responsibilities:

• Translate medical documentation into ICD-10, CPT, and HCPCS codes.
• Ensure coding accuracy for inpatient, outpatient, or professional services.
• Validate codes to maximize reimbursement while maintaining compliance.
• Collaborate with providers and clinical teams to clarify documentation.
• Conduct coding audits and assist with resolving discrepancies.
• Stay current with coding updates, payer requirements, and regulatory changes. 

Overview:
Responsible for generating, submitting, and tracking medical claims to ensure accurate and timely reimbursement for healthcare services.

Core Responsibilities:

• Prepare and submit electronic or paper claims to insurance companies and payers.
• Review billing data for accuracy and completeness before submission.
• Follow up on unpaid or denied claims, resubmitting as necessary.
• Resolve claim rejections and correct coding or documentation errors.
• Post payments, adjustments, and denials to patient accounts.
• Maintain knowledge of billing regulations, payer guidelines, and compliance standards. 

Overview:
Manages the enrollment of healthcare providers and organizations with insurance payers, ensuring eligibility to submit claims and receive reimbursement.

Core Responsibilities:

• Complete payer enrollment applications for commercial, Medicare, and Medicaid plans.
• Track enrollment status and follow up with payers to expedite approvals.
• Maintain accurate records of provider participation across payer networks.
• Collaborate with credentialing teams to synchronize enrollment and credentialing activities.
• Resolve enrollment discrepancies or denials promptly.
• Stay updated on payer-specific enrollment policies and procedures.

Overview:
Ensures healthcare providers meet all regulatory, payer, and facility requirements to practice and bill for services. Manages credentialing processes for physicians, nurses, and allied health professionals.

Core Responsibilities:

• Prepare, submit, and track credentialing applications to hospitals, payers, and regulatory bodies.
• Maintain accurate provider records and credentials in databases.
• Monitor expirations for licenses, certifications, and re-credentialing requirements.
• Communicate with providers, payers, and governing agencies to resolve credentialing issues.
• Ensure compliance with accreditation standards and state/federal regulations.
• Support audits and provide documentation as needed.