Reimbursement Specialist

The Reimbursement Specialist ensures accurate and compliant reimbursement processes, coordinating with insurance and regulatory guidelines. Reporting to the Director of Reimbursement and supervised by the Reimbursement Supervisor, responsibilities include reviewing claims, resolving billing discrepancies, and maintaining HIPAA and regulatory compliance. Ideal candidates have healthcare industry experience, proficiency in billing systems, and strong attention to detail. Essential Functions Assists in coordinating and maintaining the reimbursement program to ensure compliance with current payments, rules and legislative regulations that impact billing and collections. Monitors and evaluates current reimbursement/payment rules and policy guidelines to ensure that legislative and regulatory changes impacting medical billing are anticipated and communicated to the company. Ensures adherence to all HIPAA, JCAHO, and Compliance rules and regulations. Reviews authorization, detailed prescriptions, and verification for claims within his/her work group, to ensure that accurate claims were submitted for revenue and their medical necessity in the event the services were not paid accurately. Works towards minimizing AR within assigned workgroup by correcting and resubmitting claims, as well as submitting appeals. Communication with various insurance companies and payers to resolve billing and reimbursement discrepancies. Reviews information provided by payers regarding the reimbursement for goods and services, usually on an Explanation of Benefits (EOB) or Remittance Advice, to ensure posting of payments align with these documents and reason for non-payment or inaccurate reimbursement. Trend identification should be performed through this process and escalated to management for global resolution. Confirms and prioritizes pick-ups, exchanges, and returns on both serialized and non-serialized equipment and supplies to ensure inventory and other functional operating areas are not negatively affected. Ensures that claims are followed up in a timely manner, specifically no longer than payer requirements, to avoid write-offs. Requesting adjustments, write-offs, or refunds from manager on balances over $1,000.00. Responds to customer inquiries both in person and telephonically as necessary, including but not limited to payments on account, questions about benefits, and questions about insurance policy. Prepares and submits medical records to the various payers on request to facilitate payment for services or audit. Meet or exceed Key Performance Indicators (KPIs) and productivity in all measured areas. Performs other duties, as assigned by management. Qualifications And Requirements High School Diploma or equivalent. A background in healthcare related industry experience required. Competent level of experience in medical billing (2-3 years minimum). Experience in Brightree and/or DME preferred. Must be knowledgeable of insurance requirements, policy guidelines, and have the ability to determine medical justification by reviewing documentation to ensure proper reimbursement. Ability to type over 30 WPM and navigate computer programs accurately and efficiently. Ability to effectively operate billing software and patient portal to cover the scope of his/her job description. Competencies Attention to Detail: Exhibits meticulousness and thoroughness in task completion. Integrity: Upholds honesty and ethical conduct in all actions. Cooperation: Maintains a positive and cooperative attitude while working with others. Effective Communication: Communicates effectively through both written and verbal means. Proficiency in Microsoft Office Suite: Demonstrates adeptness in using various Microsoft Office applications. Physical Requirements Prolong periods sitting at a desk and working on a computer. Must be able to lift up to 15 pounds at times. Discrimination based on race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, disability, age (40 or older) or genetic information (including family medical history) is illegal and will not be tolerated. In addition, we will provide reasonable accommodations (changes to the way things are normally done at work) to applicants and employees who need them for medical or religious reasons, as required by law. #J-18808-Ljbffr Reliable Medical