Revenue Cycle Representative II Team Lead

Description

AIM OF THE POSITION

The Revenue Cycle Representative II Team Lead is a working lead responsible for performing advanced RCM Level II responsibilities while providing day-to-day operational support, training assistance, and subject-matter guidance to the RCR II team.

The Team Lead will maintain a reduced alpha account assignment to allow sufficient capacity to support team members, assist with onboarding and training, provide guidance on appeals, medical record reviews, and payer escalations, and support review criteria and special projects assigned by RCM leadership.

The Team Lead is not a people manager and does not replace the responsibilities or authority of the RCM Supervisor/Manager.

POSITION WITHIN THE ORGANIZATION

1. Reports to Reimbursement Supervisor

2. Cooperates with all departments across the organization

3. Organizes activities with Managed Care, IT, Commercial, Sales, Customer Care and external vendors

4. Participates in:

– Department meetings

– Project meetings

– Working groups

– Project groups

Requirements

ESSENTIAL DUTIES AND RESPONSIBILITIES

Key Responsibilities

· Maintain a reduced alpha split of RCR II accounts and perform Level II account responsibilities.

· Serve as the first point of operational support for RCR II team members.

· Assist with onboarding and training of new RCR employees.

· Provide guidance on complex appeals, medical record reviews, payer requirements, and escalations.

· Assist team members with determining appropriate appeal and escalation strategies.

· Reinforce payer-specific workflows, documentation requirements, and departmental standards.

· Monitor complex account inventory and identify aging, appeal, or escalation concerns.

· Assist leadership with denial reviews, payer criteria projects, medical record reviews, and revenue recovery initiatives.

· Support quality-control reviews and identify recurring errors or knowledge gaps.

· Communicate payer trends, systemic issues, and recommended solutions to the RCM Supervisor/Manager.

· Assist with special projects involving payer policies, reimbursement, denial trends, and account resolution.

· Provide operational coverage when necessary.

· Maintain patient confidentiality and HIPAA compliance.

· Perform all responsibilities of the RCR II role when performing assigned account work.

Lead Allocation

Recommended workload allocation:

· 75% — RCR II production/account responsibilities

· 25% — Team Lead responsibilities

The Team Lead’s alpha assignment should be smaller than a standard RCR II alpha split to ensure sufficient capacity for training, team support, and leadership-assigned projects.

Performance Measures

· Cash recovery

· Appeal overturn rate

· Aging reduction

· Appeal timeliness

· Quality/error rate

· Team support responsiveness

· Training/onboarding effectiveness

· Accuracy of review criteria

· Special-project completion

· Documentation and compliance

Appeals & Denial Resolution

· Manage assigned complex non-paid and underpaid accounts requiring advanced intervention.

· Research and prepare payer appeals in accordance with payer-specific requirements.

· Review denial reasons, payer policies, medical necessity criteria, coding information, authorization requirements, and supporting documentation.

· Develop clear and accurate appeal documentation supporting reimbursement.

· Track appeal submission, payer response, reconsideration, and escalation timelines.

· Identify opportunities for appeal overturns and revenue recovery.

· Escalate unresolved payer issues according to established RCM escalation protocols.

· Identify recurring denial trends and communicate findings to RCM leadership.

Medical Records Review

· Review medical records and supporting documentation to determine whether payer requirements and medical necessity criteria are met.

· Coordinate with internal clinical, coding, billing, or operational teams when additional documentation is required.

· Determine documentation needed to support appeals and payer reconsiderations.

· Identify documentation deficiencies contributing to non-payment or underpayment.

· Support projects involving medical record review, payer criteria, and revenue recovery.

Payer Escalation

· Manage complex payer issues that cannot be resolved through routine follow-up.

· Research payer policies, contracts, authorization requirements, and claim-processing issues.

· Prepare escalation documentation for RCM leadership and/or Managed Care when appropriate.

· Maintain detailed documentation of payer communications and escalation activity.

· Partner with Managed Care on contract, reimbursement, credentialing, and systemic payer issues when directed.

· Identify systemic payer trends and recommend opportunities for resolution.

Alpha Split Partnership

· Support the RCR I representative assigned to the same alpha population.

· Provide guidance on complex accounts and determine when an account requires Level II intervention.

· Review escalated accounts and provide direction regarding appropriate next steps.

· Communicate outcomes of appeals, medical record reviews, and payer escalations back to the RCR I representative.

· Promote consistent account-resolution practices across the assigned alpha population.

Productivity & Quality

· Maintain assigned inventory within established aging and follow-up standards.

· Meet established productivity, cash recovery, appeal, quality, and account resolution expectations.

· Maintain accurate and complete documentation in the applicable RCM systems.

· Participate in audits, quality reviews, denial analysis, and revenue recovery initiatives.

· Identify opportunities to improve payer performance, reduce denials, and accelerate cash realization.

Incoming Communication Coverage

· Incoming patient phone calls, faxes, and emails are not a routine responsibility of the RCR II role.

· Provide coverage when directed by RCM leadership due to staffing shortages, increased volume, or other operational needs.

Other Responsibilities

· Participate in RCM projects, payer initiatives, and process-improvement activities.

· Assist with training and knowledge sharing when requested.

· Perform other duties as assigned by RCM leadership.

KEY CONTACTS

Internal

o This position may interface with all departments within the company.

External

o External Vendors

EDUCATION AND EXPERIENCE REQUIREMENTS

Required Qualifications

· High school diploma or equivalent required.

· 3+ years of healthcare revenue cycle, medical billing, collections, appeals, denial management, or related experience preferred.

· Strong healthcare payer and claims knowledge.

· Experience with appeals and medical record review preferred.

· Laboratory, healthcare, hospital, physician, ASC, or other medical billing experience preferred.

· Strong analytical, written, and verbal communication skills.

· Strong understanding of payer policies and claim resolution processes.

· Ability to research complex issues and independently determine appropriate resolution strategies.

· Strong organizational skills and attention to detail.

· Proficiency with Microsoft Office and healthcare billing/RCM systems.

· Ability to maintain patient confidentiality and comply with HIPAA requirements.

Core Competencies

· Advanced Revenue Cycle Knowledge

· Appeals & Denial Management

· Medical Records Review

· Payer Escalation

· Analytical Thinking

· Revenue Recovery

· Problem Solving

· Account Resolution

· Communication

· Accountability

· Teamwork

· HIPAA Compliance

Performance Measures

Performance will be evaluated based on established departmental RCM metrics, which may include:

· Cash recovery

· Appeal overturn rate

· Aging inventory reduction

· Appeal timeliness

· Account resolution

· Medical record review accuracy

· Productivity

· Quality/error rate

· Payer escalation resolution

· Documentation accuracy

· Compliance with RCM policies and procedures

KNOWLEDGE, SKILLS AND ABILITIES (KSA’S)

Specific Knowledge Required:

Knowledge: Comprehension of a body of information acquired by experience or study.

Skill: A present, observable competence to perform a learned activity.

Ability: Competence to perform observable behavior.

• Advanced technical knowledge of Microsoft products required (Excel, Word, Outlook)

• Must be able to work in a fast-paced environment

• Must have strong organizational skills and attention to detail

• High degree of accuracy

• Manage multiple tasks independently

• Other skills necessary are accounting, data entry, general math, analytical, thoroughness, research, verbal/written communication

BEHAVIOURAL COMPETENCIES/DESIRED SKILLS

• Excellent problem resolution

• Excellent customer service skills

• Outside-the-box thinker

WORKING ENVIRONMENT

Establishes ADA (Americans with Disabilities Act) requirements

ENVIRONMENT/SAFETY/WORK CONDITIONS

Working conditions (inside or outside the office).

• This is an in-office position and is not remote

• General office environment. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Maintains a clean, neat, and orderly work area.

• Adheres to Department Specific Safety Guidelines.

• Standing, sitting, walking, bending, reaching, manual manipulation, and lifting up to 15 pounds.

TRAVEL

· No travel is required

OTHER DUTIES

Other duties as required by management