Major Medical Collector HYBRID

Job Description

Job Description

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

The Major Medical Collector is responsible for managing complex insurance accounts receivable for specialty home infusion pharmacy, infusion nursing services, ambulatory infusion center (AIC), and home health claims. This position focuses on maximizing reimbursement by aggressively pursuing payment of outstanding claims, researching payment discrepancies, resolving denials, preparing appeals, and ensuring timely collections from Medicare, Medi-Cal, Managed Medi-Cal, Medicare Advantage, Commercial PPO/HMO plans, Workers' Compensation, and other third-party payers.

This role requires an advanced understanding of specialty infusion medications, home infusion billing, pharmacy reimbursement methodologies, medical necessity requirements, prior authorization, and payer-specific reimbursement guidelines. The Major Medical Collector serves as a subject matter expert and collaborates closely with Intake, Authorization Specialists, Pharmacists, Nurses, Billing, Reimbursement, Managed Care, and Finance to reduce accounts receivable aging while improving reimbursement performance.

This position is offered under a hybrid work model .

Essential Duties and ResponsibilitiesAccounts Receivable Management

• Manage an assigned portfolio of complex insurance accounts receivable for specialty home infusion pharmacy and home health services.
• Review daily, weekly, and monthly aging reports to prioritize collection activities.
• Research and resolve unpaid, underpaid, denied, and suspended claims.
• Monitor high-dollar infusion claims to ensure timely reimbursement.
• Identify reimbursement barriers and develop strategies to accelerate payment.
• Maintain productivity standards for insurance follow-up and collections.

Insurance Collections

• Conduct comprehensive insurance follow-up with:
  • Medicare
  • Medicare Advantage
  • Medi-Cal
  • Managed Medi-Cal
  • Commercial PPO and HMO plans
  • IPA Medical Groups
  • Workers' Compensation carriers
  • Third-party administrators
• Communicate directly with insurance representatives regarding outstanding claims, payment status, appeals, authorizations, and reimbursement issues.
• Resolve coordination of benefits (COB), eligibility issues, medical necessity denials, authorization discrepancies, and contractual payment variances.
• Escalate unresolved payer issues appropriately while maintaining professional payer relationships.

Denials & Appeals

• Investigate claim denials to determine root causes.
• Prepare first-level, second-level, and external appeals with supporting clinical and billing documentation.
• Coordinate with physicians, pharmacists, nurses, authorization specialists, and intake staff to obtain documentation supporting medical necessity.
• Monitor appeal deadlines and payer response timelines.
• Track appeal outcomes and identify trends impacting reimbursement.
• Recommend operational improvements to reduce future denials.

Specialty Home Infusion Reimbursement

• Utilize advanced knowledge of specialty infusion billing requirements for therapies including, but not limited to:
  • IV Antibiotics
  • IV Immunoglobulin (IVIG)
  • Subcutaneous Immunoglobulin (SCIG)
  • Total Parenteral Nutrition (TPN)
  • Hydration Therapy
  • Biologic Medications
  • Monoclonal Antibodies
  • Anti-infective Therapies
  • Specialty Injectable Medications
• Understand reimbursement methodologies for medications, nursing services, infusion pumps, supplies, and pharmacy dispensing fees.
• Review payer policies related to infusion therapy coverage and reimbursement.

Revenue Cycle Collaboration

Collaborate closely with:

• Intake Coordinators
• Authorization Specialists
• Benefits Verification Specialists
• Clinical Pharmacists
• Pharmacy Technicians
• Home Infusion Nurses
• Ambulatory Infusion Center (AIC)
• Billing Department
• Managed Care
• Finance Department

to resolve reimbursement issues before and after claim submission.

Provide recommendations that improve clean claim rates, reduce denials, and strengthen overall revenue cycle performance.

Financial Analysis

• Review Explanation of Benefits (EOBs) and Electronic Remittance Advice (ERAs).
• Identify payment variances, underpayments, duplicate payments, and contractual discrepancies.
• Verify reimbursement against payer contracts and fee schedules.
• Assist leadership in identifying payer trends affecting revenue.
• Prepare documentation supporting recovery of underpaid claims.

Documentation

• Maintain complete documentation of all collection activities within the billing system.
• Document payer communications, appeals, claim corrections, payment status, contractual adjustments, and follow-up efforts.
• Ensure account notes support audit readiness and continuity of follow-up.

Quality Improvement

• Participate in departmental productivity meetings and revenue cycle review sessions.
• Identify trends contributing to reimbursement delays.
• Recommend workflow improvements that increase reimbursement and reduce accounts receivable aging.
• Assist with internal audits, payer audits, and accreditation activities.

Regulatory Compliance

Maintain compliance with:

• Medicare Parts B & D billing regulations
• Medi-Cal regulations
• Commercial payer reimbursement guidelines
• CMS regulations
• HIPAA Privacy and Security Rules
• ACHC Accreditation Standards
• California Board of Pharmacy regulations
• Company policies and procedures

Maintain strict confidentiality of all protected health information.

Minimum Qualifications

• High School Diploma or equivalent required.
• Associate's or Bachelor's degree in Healthcare Administration, Business Administration, Medical Billing, or related field preferred.
• Minimum 5 years of medical collections experience with a strong emphasis on specialty home infusion pharmacy required.
• Experience with home health reimbursement strongly preferred.
• Experience managing high-dollar infusion claims and specialty medication reimbursement.
• Experience with CPR+ (Mediware), CareTend, Brightree, EnterpriseRx, or similar billing platforms preferred.

Knowledge, Skills & AbilitiesRequired Knowledge

• Advanced knowledge of specialty home infusion reimbursement.
• Home infusion pharmacy billing methodologies.
• Medicare Parts B & D.
• Medi-Cal and Managed Medi-Cal reimbursement.
• Commercial PPO and HMO reimbursement.
• Pharmacy and nursing billing requirements.
• HCPCS, CPT, ICD-10-CM, modifiers, revenue codes, and NDC billing.
• Medical necessity guidelines.
• Prior authorization requirements.
• Explanation of Benefits (EOBs).
• Electronic Remittance Advice (ERA).
• Coordination of Benefits (COB).
• Appeals and payer dispute resolution.

Required Skills

• Strong analytical and critical thinking skills.
• Excellent organizational and time management abilities.
• Advanced problem-solving skills.
• Strong negotiation skills when working with insurance carriers.
• Excellent written and verbal communication.
• Intermediate to advanced Microsoft Excel skills.
• Ability to manage large volumes of complex accounts while meeting productivity standards.

Core Competencies

• Specialty Home Infusion Expertise
• Revenue Cycle Management
• Insurance Collections
• Accounts Receivable Management
• Appeals & Denial Resolution
• Financial Analysis
• Regulatory Compliance
• Attention to Detail
• Critical Thinking
• Customer Service
• Accountability
• Team Collaboration
• Problem Solving
• Continuous Improvement

Performance Expectations

The Major Medical Collector is expected to:

• Meet or exceed departmental collection and productivity goals.
• Reduce insurance accounts receivable aging.
• Maximize reimbursement for specialty infusion pharmacy and home health services.
• Maintain high-quality documentation of all collection activities.
• Resolve denials and appeals within established turnaround times.
• Maintain compliance with all payer, regulatory, accreditation, and company requirements.
• Identify reimbursement trends and contribute to process improvement initiatives.
• Support Oso Home Care's commitment to financial stewardship while ensuring patients continue to receive medically necessary infusion therapies.

Why Join Oso Home Care?

Founded in 1984, Oso Home Care is a privately owned leader in specialty home infusion pharmacy, ambulatory infusion center services, and home health care. We are dedicated to delivering exceptional patient care through clinical excellence, innovation, and compassionate service.

At Oso Home Care, our Billing & Reimbursement team plays a vital role in supporting patient access to life-sustaining infusion therapies. We offer a collaborative, family-oriented work environment, opportunities for professional growth, and the chance to make a meaningful impact on both our patients and our organization.

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 characteristic protected by federal, state, or local law.