Reimbursement Specialist

Job Description

Job Description

Position Summary

Oso Home Care is seeking an experienced Home Infusion Biller to join our Billing & Reimbursement Department. Since 1984, Oso Home Care has been a leader in specialty home infusion pharmacy, ambulatory infusion center (AIC) services, and home health throughout Southern California.

The Home Infusion Biller is responsible for the accurate and timely billing of specialty infusion pharmacy medications, supplies, nursing services, and ambulatory infusion center (AIC) services. This position manages the billing process from claim creation through reimbursement by ensuring claims are submitted accurately, claim edits are resolved, denials are appealed, and insurance follow-up is completed in accordance with payer requirements.

The Home Infusion Biller works closely with Intake, Authorization Specialists, Benefits Verification, Pharmacy, Nursing, Reimbursement, and Revenue Cycle teams to ensure complete documentation, accurate billing, and timely reimbursement while maintaining compliance with Medicare, Medi-Cal, commercial insurance, and accreditation standards.

• Prepare, review, and submit accurate electronic and paper claims for home infusion pharmacy services, infusion nursing visits, ambulatory infusion center (AIC) treatments, specialty medications, and related services.
• Ensure all billing is supported by physician orders, nursing documentation, delivery records, medication administration records, and required clinical documentation.
• Submit claims utilizing appropriate HCPCS, CPT, ICD-10-CM, NDC, modifiers, and payer-specific billing requirements.
• Review claims for completeness and accuracy prior to submission.
• Ensure claims are billed within established departmental turnaround standards.

• Review electronic claim edits and clearinghouse reports.
• Correct billing errors and resubmit rejected claims.
• Resolve claim edits related to coding, documentation, eligibility, authorization, or payer requirements.
• Monitor claim acceptance and payment status through payer portals and electronic remittance systems.

• Research denied and partially paid claims.
• Determine the cause of denials and implement corrective actions.
• Prepare corrected claims and supporting documentation for resubmission.
• Submit appeals when appropriate and monitor payer response timelines.
• Collaborate with Intake, Authorization Specialists, Pharmacy, Nursing, and physician offices to obtain additional documentation needed for reimbursement.

• Follow up on outstanding claims with Medicare, Medi-Cal, Managed Medi-Cal, Medicare Advantage, PPO, HMO, and commercial insurance carriers.
• Review Explanation of Benefits (EOBs) and Electronic Remittance Advice (ERAs) for payment accuracy.
• Resolve claim payment discrepancies, coordination of benefits (COB), underpayments, and contractual adjustments.
• Maintain detailed documentation of all payer communications and account activity.

• Work collaboratively with Intake, Authorization, Benefits Verification, Pharmacy, Nursing, and Reimbursement teams to resolve billing issues that impact reimbursement.
• Identify trends that contribute to billing delays or denials and communicate recommendations for process improvement.
• Assist with payer audits, documentation requests, and reimbursement reviews.

• Maintain compliance with:
  • Medicare and Medi-Cal billing regulations
  • Commercial payer billing requirements
  • CMS reimbursement guidelines
  • HIPAA Privacy and Security Rules
  • ACHC accreditation standards
  • California Board of Pharmacy regulations
  • Company policies and procedures
• Maintain confidentiality of patient health information in accordance with HIPAA.

• High School Diploma or equivalent required.
• Associate degree in Medical Billing, Healthcare Administration, or related field preferred.
• Minimum of 2 years of medical billing or collections experience in Home Infusion, Specialty Pharmacy, Home Health, or Infusion Services.
• Experience with CPR+ (Mediware), CareTend, or similar healthcare billing software preferred.
• Experience billing Medicare, Medi-Cal, Managed Medi-Cal, Medicare Advantage, PPO, HMO, and commercial insurance plans.

• Thorough knowledge of medical billing procedures and revenue cycle processes.
• Working knowledge of Medicare, Medi-Cal, and commercial payer billing requirements.
• Knowledge of CMS reimbursement guidelines.
• Familiarity with HCPCS, CPT, ICD-10-CM, and NDC coding.
• Understanding of insurance eligibility, benefits verification, coordination of benefits, and prior authorization requirements.
• Knowledge of medical terminology and infusion pharmacy services.
• Proficiency with Microsoft Office Suite (Word, Excel, Outlook) and electronic medical record (EMR) systems.
• Strong analytical, organizational, and time management skills.
• Excellent written and verbal communication skills.
• Ability to prioritize multiple tasks while meeting productivity and billing deadlines.
• Strong mathematical skills with the ability to calculate payments, contractual adjustments, percentages, and reimbursement variances.

• Medical Billing
• Revenue Cycle Knowledge
• Attention to Detail
• Critical Thinking
• Problem Solving
• Time Management
• Customer Service
• Communication
• Teamwork
• Accountability
• Regulatory Compliance
• Organizational Skills

The Home Infusion Biller is expected to:

• Submit accurate and timely claims with a high clean claim rate.
• Maintain productivity standards for billing and insurance follow-up.
• Resolve claim denials within established turnaround times.
• Maintain accurate documentation of all billing activity.
• Support departmental goals related to reimbursement, accounts receivable, and cash flow.
• Maintain compliance with all payer, regulatory, accreditation, and company requirements.

Collection-based incentive opportunities may be available based on departmental performance and company policy.

Founded in 1984, Oso Home Care is a privately owned specialty home infusion pharmacy providing infusion therapy, ambulatory infusion services, and home health care throughout Southern California. We are committed to delivering exceptional patient care through clinical excellence, innovation, compassion, and teamwork.

Oso Home Care is an Equal Opportunity Employer. Employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or any other status protected by applicable federal, state, or local law.