Reimbursement Specialist

Reimbursement Specialist

Reimbursement Specialist

Job Code: RS - 111

Revision Date: November 9, 2022

Starting Salary: $18.59 hourly; $38,667 annually

FLSA: Non-Exempt

Overview

We are an agency committed to innovative behavioral health services in trauma-informed care that promote healing and recovery to instill a sense of empowerment and foster a lifelong sense of resilience.


General Description

The basic function of the Reimbursement Specialist is to analyze the billing process to determine appropriateness in payment (reimbursement). This position is responsible for handling all components of claims processing including coordination of disputed, rejected and delayed claims and to review returned, disputed or rejected claims from Medicare, Medicaid and other third-party payers and problem solve. This position is responsible for communicating and training other departmental staff regarding revenue cycle processes to prevent future denials

This class works under general supervision, independently developing work methods and sequences.


Duties and Responsibilities

The functions listed below are those that represent the majority of the time spent working in this position. Management may assign additional functions related to the type of work of the position as necessary.

• Provides technical assistance to members of other departmental staff.
• Reviews remittances and determines reasons for denial or underpayment.
• Works with TMHP, Medicare, and all other Insurance Companies in order to resubmit claims for maximized reimbursement.
• Reviews and updates account receivables database and takes appropriate action regarding any unbilled, denied, or underpaid claims.
• Reports and reconciles all unbilled, denied and underpaid claims.
• Recommends to Supervisor which accounts should be written off and ensures write off process has been followed
• Assists Chief Financial Officer with special billing reports as required.
• Responsible for validating appeal opportunities, creating appeal letters, generating and submitting individual and/or batch appeals in a timely manner, tracking appeals and recoveries. Follow up on outstanding appeals, working closely with the appropriate teams to validate contracts, and verifying credentialed status.
• Attends all workshops offered in the area for Medicaid, Medicare and/or Managed Care Organizations as well as any webinars provided.
• Provides updated information to supervisor regarding any changes in fee schedule, procedure codes, contact information and/or limitations of benefits.
• Communication with Manager regarding Registration, Billing or Posting issues. Review these areas of inaccurate information and determine if there needs to be additional education/training with other departments.
• Provide written documentation and training to appropriate staff as reimbursement issues are identified.
• Understand insurance carrier guidelines and stay abreast of any changes that occur in order to communicate them to the Management (specifically Director of Revenue Cycle) and staff.
• Monitor the bundling process that each carrier has in place and ensure guidelines are followed.
• Assist with Yearly and Individual Provider audits, as needed.
• Works well with supervisor and all others in positions of authority.
• Maintains cooperative working relationship with all personnel.
• Promotes a high degree of morale and spirit of motivation within the office. This includes the degree of cooperation, communication and coordination between this function and other employees.
• Demonstrates ability to tactfully handle difficult situations.
• Consistently shows ability to recognize and deal with priorities.
• Performs other duties as assigned.

Minimum Education and Experience Requirements

Requires Associate's Degree, supplemented by (1) year of experience in billing in a medical or behavioral health setting; or any equivalent combination of education, training, and experience which provides the requisite knowledge, skills, and abilities.


Experience with trauma-informed services; cognitive behavioral therapies, including DBT; and motivational therapies including the use of incentives, preferred.


Required Knowledge and Abilities

Knowledge of trauma-informed theories, principals, and practices (includes multi-faceted understanding of concepts such as community trauma, intergenerational and historical trauma, parallel processes, and universal precautions), preferred.


Physical Demands

Performs sedentary work that involves walking or standing some of the time and involves exerting up to 10 pounds of force on a regular and recurring basis or sustained keyboard operations.

Unavoidable Hazards (Work Environment)

• Involves routine and frequent exposure to:
• Bright/dim light; Dusts and pollen.
• Other extreme hazards not listed above.

Special Certifications and Licenses

• Must possess and maintain a valid state Driver's License with an acceptable driving record.
• Must be able to pass a TB, criminal background and drug screen.

Americans with Disabilities Act Compliance (ADA)

Emergence Health Network is an Equal Opportunity Employer. ADA requires Emergence Health Network to provide reasonable accommodations to qualified persons with disabilities. Prospective and current employees are encouraged to discuss ADA accommodations with management.

Other Job Characteristics

• Staffing requirements, including criteria that staff have diverse disciplinary backgrounds, have necessary State required license and accreditation, and are culturally and linguistically trained to serve the needs of the clinic's patient population.
• Credentialed, certified, and licensed professionals with adequate training in person-centered, family centered, trauma informed, culturally-competent and recovery-oriented care.

Note: This Class Description does not constitute an employment agreement between the Emergence Health Network and an employee and is subject to change by the Emergence Health Network as its needs change.