Claims & Revenue Cycle Specialist

Core Focus

The Claims & Revenue Cycle Specialist’s core focus is to ensure claims, payments, denials, credentialing, and patient billing tasks are completed accurately and on time.

This role helps protect ABA Spectrum’s revenue by keeping claims clean, payments posted, denials moving, and balances actively managed.

Role Breakdown

The Claims & Revenue Cycle Specialist is responsible for:

• Credentialing new providers with payers.
• Auditing and cleaning up billing entries.
• Submitting claims weekly.
• Posting payments timely and accurately.
• Invoicing and collecting patient responsibilities.
• Addressing claim denials, rejections, and billing errors.
• Monitoring payer portals and claim status.
• Documenting all account activity.
• Communicating billing concerns to the Revenue Cycle Manager.

Core Responsibilities

Claims Submission

• Review billing entries for accuracy before claims are submitted.
• Audit sessions, billing codes, modifiers, provider information, authorization information, and payer requirements.
• Clean up billing errors before claim submission.
• Submit claims weekly according to ABA Spectrum’s revenue cycle schedule.
• Ensure claims are submitted within timely filing limits.
• Track submitted claims and monitor claim status.
• Identify missing or inaccurate information that may delay reimbursement.
• Notify the Revenue Cycle Manager of repeated billing entry issues or trends.

Denials, Rejections & Claim Errors

• Review denied, rejected, delayed, or unpaid claims.
• Work assigned denial tasks, work queues, reports, and payer follow-up lists.
• Correct claim errors and resubmit claims when appropriate.
• Prepare corrected claims, reconsiderations, and appeals.
• Gather supporting documentation for payer requests.
• Communicate with payers to understand denial reasons and required next steps.
• Document all payer communication and claim activity.
• Escalate complex or repeated payer issues to the Revenue Cycle Manager.

Payment Posting

• Post insurance payments accurately and timely.
• Post patient payments accurately and timely.
• Review EOBs and EOPs to confirm payment amounts, adjustments, denials, and patient responsibility.
• Identify payment discrepancies, underpayments, recoupments, or overpayments.
• Notify the Revenue Cycle Manager of unusual payment trends.
• Ensure payment posting records are organized and accurate.

Patient Responsibility Billing & Collections

• Invoice families for patient responsibility balances.
• Monitor patient balances and follow ABA Spectrum’s collection procedures.
• Communicate with families regarding balances, invoices, and payment questions.
• Document all family billing communication.
• Track payment plans and notify the Revenue Cycle Manager of missed payments or high-risk balances.
• Maintain empathy and professionalism when discussing financial responsibility with families.

Provider Credentialing & Payer Enrollment

• Complete credentialing tasks for new providers.
• Maintain accurate provider credentialing records.
• Track payer enrollment status and follow up with payers as needed.
• Update CAQH or payer systems as assigned.
• Notify the Revenue Cycle Manager of credentialing delays that may impact billing.
• Coordinate with HR, leadership, and clinical teams to obtain needed provider information.

Payer Portal Management

• Navigate payer portals to monitor claim status, payment status, eligibility, and payer requests.
• Review payer messages, tasks, and correspondence.
• Respond to payer requests timely.
• Upload or submit documentation as needed.
• Maintain organized records of payer activity.
• Notify the Revenue Cycle Manager of payer system issues or recurring problems.

Documentation & Task Management

• Accurately document all activity and communication on accounts.
• Work assigned task lists, work queues, reports, and special projects.
• Monitor email and assigned tasks throughout the day.
• Prioritize work based on deadlines, claim age, payer requirements, and revenue risk.
• Maintain confidentiality and follow HIPAA requirements.
• Complete assigned tasks by expected deadlines.

Key Metrics / Scorecard

The Claims & Revenue Cycle Specialist is accountable for the following metrics:

• Claims submitted weekly.
• Percentage of claims received/paid.
• Claim submission accuracy.
• Billing entries audited and cleaned up timely.
• Payment posting completed timely.
• Payment posting accuracy.
• Denials addressed within expected timeframe.
• Claim errors corrected timely.
• Appeals or corrected claims submitted timely.
• Patient invoices sent timely.
• Patient balances followed up according to policy.
• Credentialing tasks completed by deadline.
• Documentation of account activity completed accurately.

What Success in This Role Looks Like

A successful Claims & Revenue Cycle Specialist:

• Submits clean claims consistently and on time.
• Keeps assigned billing tasks current.
• Posts payments accurately and timely.
• Follows up on denials and claim errors without delay.
• Maintains organized and accurate documentation.
• Communicates payer issues clearly to the Revenue Cycle Manager.
• Helps families understand billing questions with professionalism and empathy.
• Supports healthy cash flow for ABA Spectrum.
• Takes ownership of tasks and follows through until resolved.

Talents & Essential Behaviors

Considers the Big Picture

• Understands that accurate claims, payment posting, and follow-up directly impact ABA Spectrum’s ability to serve families.
• Recognizes when small errors can create larger reimbursement problems.
• Communicates trends or repeated issues to the Revenue Cycle Manager.

Fosters Collaboration

• Works well with the Revenue Cycle Manager, Finance, Patient Enrollment, Authorizations, Patient Care, and Clinical teams.
• Asks clear questions when information is missing.
• Supports team members by providing timely billing updates.

Communicates Effectively

• Communicates clearly and professionally with payers and families.
• Documents account activity in a way others can understand.
• Provides timely updates when claims, payments, or credentialing issues arise.

Manages Priorities Effectively

• Handles multiple claim issues, payer portals, invoices, and payment posting tasks.
• Prioritizes work based on urgency and deadlines.
• Completes tasks accurately without needing constant reminders.

Demonstrates Attention to Detail

• Reviews information carefully before submitting claims.
• Identifies billing errors, missing information, and inconsistencies.
• Maintains accurate records and organized work queues.

Behavioral Expectations – PEEPS Aligned

Passion

• Takes pride in accurate, timely billing work.
• Understands the importance of the role in supporting ABA Spectrum’s mission.

Empathy

• Communicates respectfully with families regarding billing questions.
• Understands that financial conversations can be sensitive.

Excellence

• Maintains high standards for accuracy, documentation, and follow-through.
• Seeks to improve efficiency and reduce errors.

Positivity

• Approaches billing challenges and payer issues with a solution-focused attitude.
• Maintains professionalism during stressful or complex claim situations.

Support

• Supports the Revenue Cycle Manager and team members by completing assigned work reliably.
• Helps create a smooth and consistent revenue cycle process.

Key Relationships

The Claims & Revenue Cycle Specialist works closely with:

• Revenue Cycle Manager
• Finance
• Authorizations/Patient Financial Responsibility
• Patient Enrollment
• Patient Care Coordinator
• Clinical Directors
• BCBAs
• HR, when provider credentialing information is needed
• Insurance payers
• Families, regarding billing questions and patient balances

Education

Preferred:

• High school diploma or equivalent required.
• Associate’s degree, billing certification, medical billing training, or related coursework preferred.

Experience

Required:

• Experience with medical billing, claims processing, accounts receivable, payment posting, collections, or administrative healthcare work.
• Experience using online systems, payer portals, spreadsheets, or billing software.
• Strong attention to detail and ability to manage deadlines.

Preferred:

• Prior experience in ABA billing or behavioral health billing.
• Experience with denials, appeals, corrected claims, and EOB/EOP review.
• Experience with provider credentialing and payer enrollment.
• Experience with Aloha ABA, Motivity, QuickBooks, or similar systems.
• Knowledge of ABA CPT codes, modifiers, authorizations, and payer rules.

Skills & Abilities

• Strong data entry and accuracy skills.
• Ability to read and understand EOBs and EOPs.
• Ability to follow billing procedures and payer requirements.
• Strong organization and task management skills.
• Clear written and verbal communication.
• Ability to communicate professionally with families and payers.
• Ability to work independently while following direction.
• Ability to maintain confidentiality and follow HIPAA requirements.
• Proficiency with payer portals, spreadsheets, email, and online systems.