Revenue Cycle & Claims Oversight Specialist Department:

Operations /

Revenue Cycle Reports To:

CEO or Billing Manager Employment Type:

Full-Time Position Summary :

The Revenue Cycle & Claims Oversight Specialist serves as the internal liaison between clinical operations, front-office teams, patients, and third-party billing vendors. This role ensures charts are complete and correctly set up before claims are released, monitors the vendor's daily claims and A/R activity, verifies follow-up quality after claims are processed, and helps improve patient-balance collection. This is not primarily a claim-submission role. The focus is internal quality control, vendor accountability, reporting, and ensuring no revenue is missed due to incomplete documentation, registration errors, poor follow-up, or preventable denials.

Key Responsibilities:

Pre-Claim Chart Review. Review encounters before claims are released to confirm charts are complete, signed, and ready for billing. Verify required demographics, insurance eligibility, subscriber information, referrals, authorizations, copays, and patient balances are accurately documented. Confirm diagnosis, procedure coding, modifiers, place of service, provider information, and supporting documentation are present and aligned. Identify missing documentation, unsigned notes, incomplete charges, or registration errors and coordinate correction with providers, clinical staff, and front desk teams. Develop and maintain pre-billing checklists and workflows by service line, including primary care, urgent care, telemedicine, house calls, and RHC services. Third-Party Billing Vendor Oversight Monitor the billing vendor's daily activity, including claims submitted, claims held, rejections, denials, payments posted, appeals, and A/R follow-up. Audit a sample of vendor-worked claims to confirm notes are accurate, follow-up is timely, and the appropriate next step was taken. Review aging reports, denial reports, claim-status reports, zero-pay claims, credit balances, and high-dollar accounts. Identify claims that have not been touched appropriately or require escalation, corrected claims, reconsideration, appeal, documentation submission, or payer outreach. Track recurring payer, documentation, credentialing, and workflow issues; work with leadership and the vendor to resolve root causes. Confirm contracted reimbursement is being received and escalate suspected underpayments or improper recoupments.

Meetings, Reporting & Accountability:

Lead or coordinate weekly revenue-cycle meetings with the third-party billing vendor. Maintain a meeting agenda covering key A/R metrics, denials, aging, payer trends, unresolved high-dollar claims, patient balances, and action items. Assign owners and due dates for vendor and internal action items; follow up until completion. Provide weekly leadership reporting on claims volume, collections, A/R aging, denials, unresolved issues, and vendor performance. Monitor performance against agreed-upon service-level expectations, such as claim submission turnaround, denial resolution, A/R follow-up frequency, and aging targets. Patient Balances & Collections. Monitor patient responsibility after insurance adjudication, including copays, deductibles, coinsurance, self-pay balances, and unapplied payments. Ensure statements, text/email reminders, payment plans, and collection workflows are performed consistently and professionally. Work with front office and vendor teams to improve point-of-service collection and reduce avoidable patient balances. Review outstanding patient-balance reports and escalate accounts requiring outreach, payment arrangements, or appropriate collections action. Ensure patient communications are respectful, accurate, and compliant with applicable policies and regulations.

Required Qualifications:

2+ years of medical billing, revenue-cycle, claims follow-up, or healthcare operations experience. Strong understanding of professional medical claims, EOBs/ERAs, denials, A/R aging, patient responsibility, and payer workflows. Experience with Medicare, Medicaid, Medicare Advantage, managed Medicaid, and commercial insurance. Working knowledge of CPT, ICD-10, HCPCS, modifiers, and documentation requirements. Strong Excel/reporting skills and comfort interpreting A/R and denial reports. Highly organized, detail-oriented, and comfortable holding internal teams and external vendors accountable. Strong communication skills with the ability to work effectively with providers, staff, patients, and billing vendors. Experience with eClinicalWorks preferred.

Preferred Qualifications:

Experience supporting primary care, urgent care, telemedicine, home-visit, or Rural Health Clinic billing. Prior experience managing or auditing an outsourced billing company. CPC, CPB, CCA, or related billing/coding certification. Familiarity with Texas Medicaid and payer credentialing requirements.

Performance Expectations:

Claims are released only after timely and accurate chart setup. Third-party billing vendor activity is reviewed daily and addressed promptly. Weekly vendor meetings result in clear, documented action items and measurable follow-through. Preventable denials, delayed claims, and untouched A/R are identified and reduced. Patient-balance collection workflows are consistently monitored and improved. Leadership receives concise, reliable revenue-cycle reporting and early notice of material issues.

Pay:

$18.00 - $25.00 per hour

Benefits:

401(k) Dental insurance Employee discount Health insurance Paid time off Vision insurance

Work Location:

In person