Medical Revenue Cycle Specialist – Pediatric Private Duty Nursing

About the Role

We are looking for a committed Medical Revenue Cycle Specialist to specialize in Pediatric Private Duty Nursing. Your work will be vital for handling the administrative and authorization tasks needed for uninterrupted patient care. You will act as a primary resource for handling medical billing, insurance authorization, and clinical documentation, allowing healthcare providers to concentrate on their clinical tasks while you handle the back-end revenue cycle processes. This role exists within an expanding boutique business process outsourcing environment that prioritizes excellence, operational performance, and a helpful, results-oriented workplace.

Requirements

• You should possess professional experience in revenue cycle management, healthcare administration, or medical billing, with expertise in prior authorization, insurance verification, and benefit eligibility.
• You must exhibit high levels of organization to handle several patient cases at once and show extreme precision when reviewing patient records and clinical documentation.
• You need to be proficient in using electronic patient management systems, spreadsheets, and various tracking tools.
• Prior experience in Private Duty Nursing or pediatric home health is preferred, as is experience with Medicaid Managed Care Organizations, NJ Medicaid, and tools like Availity, HHAeX, or AlayaCare.
• You must be proficient in managing complex reauthorization tasks, Form 485, and Letters of Medical Necessity while upholding strict standards for data privacy and professional communication.

Responsibilities

• You will assess incoming patient referrals and gather essential clinical and demographic data to begin coverage processes.
• You will confirm insurance eligibility, manage the delivery of authorization and reauthorization files, and communicate with Utilization Management teams.
• You will track the progress of open requests, engage with payers to fix problems, and manage Single Case Agreements, Gap Exceptions, and appeals.
• You will track patient authorization files, adjust case information in HHAeX and AlayaCare, and notify scheduling teams of authorized service timeframes.
• You will conduct routine dashboard analysis, oversee compliance standards, refer clinical problems to qualified medical staff, and deliver regular updates to stakeholders to foster operational refinement.

Benefits & Perks

• You will work in a completely remote environment using a Work-from-Home PLUS model.
• You will join an uplifting, supportive, and performance-based company environment that values career advancement and offers ample paths for long-term professional growth.