Job Description

POSITION: REVENUE CYCLE SPECIALST

Who We Are:

OptiMed Health Partners optimizes health outcomes and quality of life through personalized and coordinated care. We have been serving patients for over 30 years with a focus on high-quality care in retail pharmacy, specialty pharmacy, and infusion services. The OptiMed Vision reimagines healthcare solutions to achieve unsurpassed value. Our results-oriented culture fosters learning, providing growth opportunities for our employees and exceptional care for our patients in all 50 states.

The Impact of this Role:

The Revenue Cycle Specialist plays a crucial role in ensuring the financial health and operational efficiency of the organization by overseeing accurate billing, reimbursement, and care coordination for infusion services. By auditing vendor performance, verifying insurance coverage, securing prior authorizations, and managing claims and denials, this role directly supports timely patient access to care and maximizes revenue capture. Their expertise in payer requirements, coding standards, and compliance regulations helps prevent costly errors, reduce delays, and maintain strong payer relationships. Through collaboration with internal teams and external partners, the Revenue Cycle Specialist strengthens workflow integrity and enhances both the patient and provider experience.

What You’ll be Doing:

The responsibilities of the Revenue Cycle Specialist include, but are not limited to:

• Work with vendors and audit the vendor’s completion of comprehensive benefit investigations to verify patient coverage and eligibility.
• Audit to ensure compliance with payer-specific prior authorization requirements and documents to secure necessary approvals and moving patients to the next step in process
• Review the accurate collection and reconciliation of patient and third-party funds via audit of vendor follow up.
• Help leadership train and provide education via audits for vendors to perform accurate coding of billable services in accordance with current coding standards and payer guidelines.
• Submit claims and monitor their status to ensure timely and accurate reimbursement.
• Resolve claim edits and denials efficiently.
• Aid Vendors in the posting of payments from both payers and patients, ensuring accuracy and compliance with internal controls.
• Maintain a strong working knowledge of EMR systems, healthcare compliance standards, and applicable federal and state regulations.
• Establishing and maintaining relationships with third parties such as vendors and payers.
• Coordinating care with all parties involved.
• Working on any denials or claims requests such as appeals, resubmissions or additional documentation requests.
• Working with leadership to create and keep SOPs up to date and available for vendors to utilize.
• Back up to Front desk/administration assistance, if the candidate is local.

Who You’ll be Working With: The Revenue Cycle Specialist is responsible for working directly with patients, payers, prescribers, and other clinical and administrative staff.

Skills and Experience You’ll Bring to the Table :

• A college degree and/or at least two years’ medical coding, billing and reconciliation experience in the healthcare industry is required; Pharmacy and Infusion preferred
• Related experience in collections, finance, patient care and communications, or similar qualifications are highly desirable.
• Experience in front end intake functions and processes is beneficial.
• Strong project management and cross-functional team collaboration skills with a demonstrated ability to plan and drive results and achieve deadlines (especially pertaining to diligently working within Timely Filing Constraints) is key.
• Knowledge of EMR systems, healthcare compliance and related legislation is a must. Competencies You’ll Bring to the Table:
• Key advocate for patient education on benefits, approvals and any cost shares expected.
• Outstanding verbal and written communication skills will be important as they will be a key contact point for the company and vendors.
• High level of technical savvy across multiple platforms such as Windows, Microsoft Office Suite, and healthcare-related software such as payor portals, EMR systems, clearinghouse, etc.
• Ability to maintain and adhere to a strict level of confidentiality, demonstrate
• Outstanding judgement and be able to manage multiple tasks or projects simultaneously.

Work environment: The Revenue Cycle Specialist thrives in a fast-paced work environment. They must be able to sit for prolonged periods of time at a desk and perform work on a computer in an office environment. Light to moderate lifting may be required at times. Reasonable accommodation can be made to enable individuals with disabilities to perform the essential job functions. The position is remote but may require occasional visits to our Headquarters in Kalamazoo, MI, for meetings or training.

OptiMed Health Partners provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

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