Revenue Cycle Specialist

Commonwealth Care Alliance
July 14, 2019
Boston, MA
Job Type


Under the guidance of the Manager of Billing, Coding, & Provider Documentation the Revenue Cycle Specialist will enhance our FFS & Encounter process, corrective coding, and charge capture. In addition to the coding and billing responsibilities, the Revenue Cycle Specialist will work with Clinicians to perform charge entry quality assurance in eClinicalWorks (EHR) and ensure accurate billing. In addition, the Specialist will review denied claims and produce trend analysis reports to support provider education and training.



  • Assess information about patient treatment, diagnosis, and related procedures to ensure proper billing charge entry
  • Direct Data Entry of claims
  • Process and reconcile payments from insurance companies
  • Strong working knowledge of LCDs & NCDs to ensure proper payment
  • Follow up on all filed insurance claims for acceptance or denial
  • Investigate rejected claims and instances of insurance fraud
  • Escalates complex billing and insurance issues to the Billing Manager
  • Produces trend reports to support provider training
  • Works in conjunction with Billing Manager to implement best practices and work flow enhancements based upon payer billing requirement changes
  • Resubmits claims by utilizing a variety of EDI technologies and relevant billing systems to reduce aged rejections.
  • EDI transmitting and rejection review.
  • Knowledge of industry and Payer requirements to ensure accuracy of claim data, required for claims acceptance and payment.
  • Validate address completion, provider number requirements, member id requirements, filing limit restrictions and all coding requirements (HCPCS, CPT, Diagnoses, and Procedures included).
  • Identify and resolve claim deficiencies and reference registration processes and system functionality in order to resolve and resubmit timely.
  • Active and consistent follow up to various payers to resolve issues of nonpayment
  • Submit appeals as needed
  • Provides consultation and support to other members of CCA Care Team
  • Maintains appropriate written and oral communication on a timely basis
  • Actively participates in the evaluation of own performance and progress
  • Participates in activities and education to maintain and advance competency
  • Participates in CCA quality improvement efforts
  • Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects
  • Participates in committees and workgroups that promote clinical excellence and help to advance CCAs mission and business objectives

Secondary Responsibilities

Approves timecards. This position is responsible for managing subordinates.


Adhere to all applicable compliance requirements including but not limited to

Expectations of all Employees Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and members. Approach work in a collaborating and caring manner interacting with insight, sincerity, and compassion. Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering environment where the focus is on solving problems and learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of CCA’s mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and openness to change. Represent CCA and its clinical affiliates with professionalism. Keep current and proficient with necessary skills and knowledge. Self-identify training and development needs relevant to work area and responsibilities.

Complete required compliance training in a timely manner Review Code of Conduct at least annually and promote and enforce CCA’s Code of Conduct Promote and enforce CCA’s compliance program Adhere to CCA’s Policy & Procedures Promptly, in good faith, report any instances of suspected fraud, waste and abuse; suspected privacy and/or security incidents; or any compliance concerns identified Ensure confidentiality of member and company proprietary information is maintained.

Minimum Education Required


Associate's Degree or equivalent experience

Preferred Educational Experience

Associates Degree required

Minimum Years Experience Required

2+ years

Minimum Experience

2+ years

  • Certified Professional Coder (CPC) certification with the American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) certification preferred.
  • Certificate in Billing and Coding from an accredited programKnowledge, Skills and Abilities
      • Minimum of 2 years experience in medical billing and/or coding in an outpatient setting
      • Strong experience/knowledge in medical billing and/or coding in an outpatient setting. Working knowledge of medical terminology.
      • Must be knowledgeable in payer reimbursement and coding guidelines.
      • Must have knowledge of current Medicare, Medicaid, and other third-party billing requirements..
      • Proficient in the use of EMR/ EHR software and MS Office Suite. Able to learn new systems and databases that CCA implements.
      • Excellent organizational skills
      • Excellent written and verbal communication skills.
      • Excellent detail-orientation
      • Ability to read and understand oral and written instructions.
      • Understanding of HCPC and ICD–10 revenue codes
      • Familiarity with processing correspondence with adherence to HIPPA guidelines
      • Understanding of insurance guidelines
      • Competent in reading and understanding processing claim forms
      • Knowledge of appeals and denials process

    Working Conditions


Company Description

Commonwealth Care Alliance is far more than a health insurance company.

We’re a “nonprofit medical care delivery organization” with a unique care model that’s patient-centric, team-based, comprehensive, and flexible. Using this model, Commonwealth Care Alliance has been successfully transforming healthcare delivery since 2003.

Our Senior Care Options program is nationally recognized for providing compassionate effective healthcare that helps senior citizens in Massachusetts achieve their goals for improved quality of life. Similarly, our One Care program brings comprehensive, customized care to individuals between the ages of 21 and 64 with intellectual, physical and behavioral disabilities.

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