Hospital - Revenue Cycle Specialist III

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The Revenue Cycle Specialist III manages the billing process, including handling denials, insurance follow‑ups, and appeals based on their tier level in a hospital setting. Ensure accurate and timely submission of claims, work to resolve outstanding balances, and communicate effectively with insurance companies to maximize reimbursement. Collaborates with team members and other departments to maintain compliance with industry regulations and organizational policies, contributing to the overall success of the revenue cycle.

Works with the billing management team to submit the necessary documentation to insurance providers to facilitate claim processing while identifying and escalating billing inefficiencies. Recommend process improvements. Serves as a subject matter expert in hospital‑based billing, handles escalated level appeals, high‑level claim denials, and resolves escalated billing issues, ensuring full compliance with hospital and medical industry standards. May mentor lower‑level and newer team members.

Review and verify insurance information using technology, applications, payer websites, or by contacting third‑party payers or guarantors. Review adjudicated claims from Medicare, Medicaid, and commercial carriers for appropriate billing. Prepare and submit accurate insurance claims and appeals within required time frames and in accordance with government and payer regulations. Analyze plan guidelines against patient accounts to identify and address claim processing delays.

Address denied claims, claims pended for medical necessity, and claims pending supporting documentation by collaborating with clinic, registration, medical records, and coding teams to complete appeals. Extract patient treatment information from medical records and work with coding staff to compose appeal letters. Make recommendations for billing edits and processes to reduce denials. Resolve outstanding claims promptly, adhering to department policies and procedures.

Respond to inquiries from patients, insurance carriers, or internal departments via telephone or other forms of communication. Stay current on payer‑specific guidelines and regulations, cross‑train in department functions to provide backup as needed. Assist with training new hospital billing clerks on institutional standards and guidelines. Identify workflow improvement opportunities and collaborate with management to implement changes. Ensure all work is performed with strict confidentiality.

Handle high‑level appeals, manage escalated claims with significant financial impact, conduct root cause analysis, collaborate with leadership to set goals, participate in revenue cycle audits, adhere to production and quality goals. Perform all other duties as assigned.

Highly detail‑oriented with advanced organizational and prioritization skills. Expert proficiency in Microsoft Word, Excel, PowerPoint, and email software (e.g., Lotus Notes). Exceptional verbal and written communication skills, drafting high‑level memorandums, letters, and official correspondence. Expert knowledge of hospital billing, appeals processes, and denial management. In‑depth understanding of Medicare/Medicaid rules, regulations, and industry trends. Strong familiarity with industry best practices in revenue cycle management.

Proficiency in navigating office software, billing systems, and abstracting tools. Advanced understanding of insurance authorizations, benefits, coverage, and eligibility. Expertise in reimbursement practices and payer‑specific requirements. Ability to mentor Tier 1 and Tier 2 billers. Advanced problem‑solving and critical thinking skills with strong leadership and mentorship abilities. Exceptional organizational and management skills.

Five (5) years of medical billing experience is required. EPIC experience preferred.

UT Health San Antonio offers an excellent benefits package for its employees.

Employees who work at least 20 hours a week, with an appointment of at least 4.5 months, are…