Reimbursement/Billing Specialist

Position Overview:
The Reimbursement/Billing Specialist is responsible for a portfolio of accounts receivable and oversees the billing cycle from charge review, claims submission and follow-up. The employee is engaged in a proactive and independent collection of outstanding balances for specially handled IV Services, LLC., pharmacy accounts. The Reimbursement/Billing Specialist will serve as the technical expert for complex workflows. The specialist is responsible for handling charge review edits, claim edits and preparation, insurance follow-up, denial resolution, and necessary follow-up to ensure accurate payment.

Supervisory Responsibilities:

• None

Duties/Responsibilities:

• Maintain a portfolio of accounts receivable for the pharmacy;
• Follow accounts through the Pharmacy revenue cycle, including but not limited to: verifying patient coverage information, updating registration, completing charge review, claim edits and claim submissions, and following up with third party payers and patients to facilitate prompt resolution of outstanding account balances;
• Communicate with Revenue Cycle teams, payors and others to resolve account problems; participate in meetings as needed to address payor concerns;
• Evaluate the payment status of outstanding third-party claims and resolve impediments to payment by providing information such as medical records, itemization of charges, information regarding other insurance benefits, and explanation of charges;
• Actively participates in both external third-party audits and in internal audits and quality improvement initiatives, maintains documentation of current workflows, assists with special projects, and works closely with third party billing teams, Dalrada Corporate Accounting teams, and with Pharmacy Department Leadership and Prior Authorization teams;
• Perform complex patient account follow-up activities and actively participates in quality improvement initiatives to improve accounts receivable processes;
• Accurate and timely processing of appeals to various pertinent payers or programs;
• Review and validate adjustments to accounts in the insurance portfolio based on insurance reimbursement, coverage, contracts and services provided;
• Review charges to ensure filing to correct guarantor (e.g. work comp vs. personal/family);
• Conduct collection calls to patients with outstanding balances and negotiate full payment from patients and/or assist patients in setting up a payment plan;
• Provide education to patients on UW Health’s financial assistance policy and application process and direct patients to the appropriate resources as necessary (e.g. Financial Counseling, Patient Relations);
• Receive, document, and respond to all patient correspondence in a prompt and courteous manner; accurately document all actions taken to reconcile outstanding balances;
• Assist patients in coordinating appeal processes with their insurance company;
• Review self-pay undistributed and credit balance accounts and provide refunds to patients as necessary;
• Accurately post EFT, cash and checks made payable to IV Services, LLC., to the billing system;
• Ensure that all transactions are completed within the appropriate guidelines, policies and regulations, typically the same day received;
• Process electronic remittance files, payor work queues, and generate payment reports to balance;
• Communicate with IV Services, LLC., staff, insurance companies, financial institution and third-party payors to resolve issues related to proper posting of payments;
• Complete work on special projects, queries and reports as assigned;
• Other duties may be assigned as needed by management.

Required Skills/Abilities:

• In-depth understanding of Pharmacy billing policies and procedures including NCPDP D.0 standards;
• Proficiency in spreadsheet and database software;
• Advanced analytic ability;
• Ability to make good judgments in demanding situations;
• Effective communication skills;
• Ability to logically and accurately organize details;
• Ability to manage multiple tasks with ease and efficiency;
• Ability to work independently and be result oriented;
• Positive, can-do attitude coupled with a sense of urgency;
• Effective interpersonal skills, including the ability to promote teamwork;
• Ability to ensure a high level of customer satisfaction including employees, patients, visitors, faculty, physicians and external stakeholders;
• Ability to use various computer applications including EPIC, Microsoft Office, etc;
• Basic math skills and knowledge of general accounting principles;
• Knowledge of medical and insurance terminology, CPT, ICD coding structures, and billing forms (UB, UCF, 1500);
• Maintain confidentiality of sensitive information;
• Knowledge of local, state and federal healthcare regulations.

Education and Experience:

• An Associate degree in Business, Finance, Health Information Management, or related field preferred;
• 3-5 years  of experience in a healthcare revenue cycle or clinic operations role;
• 3-5 years of experience in an infusion pharmacy setting;
• Experience with billing within the Caretend pharmacy platform;
• Experience billing acute infusion and specialty pharmacy claims.

Physical Demands and Work Environment:

• While performing the duties of this job, the employee may be regularly required to stand, sit, talk, hear, reach, stoop, kneel, and use hands and fingers to operate a computer, telephone, and keyboard;
• Specific vision abilities required by this job include close vision requirements due to computer work;
• Light to moderate lifting may be required;
• Regular, predictable attendance is required; including quarter-driven hours as business demands dictate;
• Moderate noise (i.e., business office with computers, phone, and printers, light traffic);
• Ability to work in a confined area;
• Ability to sit at a computer terminal for an extended period;

Hourly Rate:

• $28.00 an hour

Disclaimer:

This Job Description is only a summary of the typical functions of the position or role, not an exhaustive or comprehensive list of all possible responsibilities, tasks, and duties. Additionally, responsibilities, tasks, and duties of the employee in this role might differ from those outlined in the Job Description and other duties may be assigned on a permanent or temporary basis based on business needs.

The Job Description is intended to be a general representation of the responsibilities and requirements of the job. However, the description may not be all-inclusive, and responsibilities and requirements are subject to change.

Equal Employment Opportunity

It is the policy of the Company to provide equal employment opportunities to all employees and employment applicants without regard to unlawful considerations of race, religion, color, national origin, sex, sexual orientation, gender identity or expression, age, sensory, physical, or mental disability, marital status, veteran or military status, genetic information, or any other classification protected by applicable local, state, or federal laws. This policy applies to all aspects of employment, including, but not limited to, hiring, job assignment, compensation, promotion, benefits, training, discipline, and termination. Reasonable accommodation is available for qualified individuals with disabilities, upon request.