Role Orientation: Billing & Revenue Cycle Specialist

1. Purpose of the Role

Billing staff ensure that Cognitive Organics can sustainably provide care by handling claims, payments, and revenue cycle processes in a way that is accurate, ethical, and aligned with our RHC and BH structures.

2. Primary Duties

• Verify insurance coverage and benefits as needed.
• Prepare, submit, and track claims for BH and RHC services.
• Monitor rejections, denials, and underpayments; follow up and appeal when appropriate.
• Post payments and reconcile balances.
• Communicate with payers and, when appropriate, with clients about billing matters.
• Work with clinical and operations staff to resolve coding/documentation issues.
• Help identify patterns (e.g., recurring denials) and propose improvements.

3. Key Systems & Tools

• EHR/practice management system
• Clearinghouse and payer portals
• Internal communication tools (secure email/messaging)
• Spreadsheets or reports used to track revenue and denials

4. Supervision & Chain of Command

• Immediate supervisor: Billing Lead, COO, or designated revenue cycle manager
• For coding/clinical documentation questions: NP/Clinical Director or designated coding resource
• For RHC-specific billing structure questions: RHC program lead/consultant

5. Scope & Boundaries

You can:

• Work directly with payers to submit and correct claims.
• Communicate with clients about balances and payment options within policy.
• Request clarification from clinicians about coding or documentation needs.

You must not:

• Change clinical documentation yourself.
• Instruct clinicians to document inaccurately to “make the claim pay.”
• Share detailed PHI beyond what is necessary for billing purposes.

6. RHC & Behavioral Health Connection

• You handle claims for services billed under:
  • RHC designation and
  • Traditional BH structure.
• You must understand which NPI/CCN and which rules apply to which services.
• You are a key partner in making sure we are paid correctly for integrated lab, NP, and therapy services.

7. Success in This Role Looks Like

• Clean claims, low denial rates, and timely follow-up.
• Clear, respectful communication with clients and staff.
• Strong collaboration with clinical teams to align coding and documentation.
• Compliance with payer rules, RHC requirements, and ethical standards.