The RCM Specialist I is an individual contributor role on the RCM team, responsible for front-end and mid-cycle revenue cycle tasks with a primary focus on insurance verification, claim submission, and customer service. This role ensures accurate eligibility and benefit gather across dental or medical payers, clean pre-authorization and claim generation, timely insurance processing, and a positive experience for patients and supported offices. The ideal candidate has a working knowledge of dental and medical billing processes, is detail-oriented, and is committed to delivering excellent service to both internal stakeholders and patients.

KEY RESPONSIBILITIES

• Perform all assigned RCM activities in accordance with best practices and internal SOPs.
• Verify insurance coverage and benefits for scheduled patients using payer portals or phone calls.
• Accurately enter and update insurance information in the practice management system.
• Confirm eligibility, plan limitations, and coordination of benefits to ensure claims are submitted cleanly in the appropriate billing order.
• Submit pre-determination and pre-authorizations requested by the patient or supporting practices with all necessary clinical attachments, follow-up on processing status, and notify practice of status return in a timely manner ensuring treatment is not delayed.
• Prepare and submit claims (electronic, paper, or via portal) in accordance with payer-specific requirements and timelines.
• Review rejected claims, identify causes, and resubmit corrected claims as needed.
• Respond promptly and professionally to patient and office inquiries related to billing, insurance coverage, and balances.
• Assist in creating and sending patient statements and following up on outstanding balances as directed.
• Document all insurance verification results, pre-authorization and claim submissions, and patient interactions thoroughly and clearly.
• Escalate issues related to claim delays, system errors, or patient concerns to the appropriate RCM team members or supervisors.
• Maintain compliance with HIPAA, payer guidelines, and internal policies.
• Participate in team meetings and training sessions to stay current on processes, tools, and payer updates.
• Support other RCM functions as needed to ensure a smooth and efficient revenue cycle process.
• Support RCM management in understanding and self-identifying contributing factors to site-specific RCM KPIs, highlighting areas of concern and areas for improvement. KPIs include but may not be limited to:
• Collection Rate: Monitor and report on the net collection rate, analyzing performance against targets. Collaborate with the team to identify opportunities for improvement.
• Days in AR: Track and evaluate average days in AR to ensure appropriate advanced collection, payment application, efficient and accurate claim filing, and timely back-end billing and claim resolution. Investigate and address any delays or bottlenecks that may be causing extended days in AR.
• % AR Over 90 Days: Review and analyze the percentage of AR over 90 days (insurance v. patient) to identify trends or issues requiring attention. Work with the team to reduce the percentage of aged receivables by implementing strategies to resolve outstanding claims and payments.
• Maintain respect and professionalism in all interactions with internal stakeholders, patients, payers, third parties, and others

• Prior experience in Dental Office workflows, Revenue Cycle functions to include Scheduling, Registration, Insurance verification, fee schedules, claim submission, charging/coding requirements, insurance AR follow up and payment posting process
• Must be knowledgeable of reimbursement/compliance process and procedures with all payors
• Experience with practice management software systems, insurance portals, clearing houses, insurance guidelines, banking reconciliation software, proficient in intermediate PC skills (MS Office—strong excel skills). Strong computer literacy, Excellent Math and problem-solving skills. Data entry and 10-key by touch.
• Strong interpersonal and organizational skills. Ability to work within a team setting and as an individual contributor. Excellent oral and written communication skills
• Responsible for quality work, meeting deadlines, and adherence to Compliance and Revenue cycle standard operating procedures
• Organized work habits, accuracy, and proven attention to detail with strong analytical skills
• Responsible for quality work, meeting deadlines, and adherence to Compliance and Revenue cycle standard operating procedures
• Certified Professional Coder (CPC) or Certified Revenue Cycle Professional (CRCP) credentials preferred