Public Provider Reimbursement Specialist

Public Provider Reimbursement Specialist

The Public Provider Reimbursement (PPR) Department within Health Care Finance Solutions (HCFS) unit conducts statewide business services for several health and human services agencies of the Executive Office of Health and Human Services (EOHHS) to maximize revenue for the Commonwealth of Massachusetts. Revenue is obtained from private, state and federal resources to reimburse the Commonwealth for the costs of health care and related services provided by public institutions and community-based programs. The PPR Specialist is responsible for performing medical billing and claiming functions, activities to identify and coordinate access to health care insurance and related benefits, and administrative and clerical duties.

Responsibilities

Essential Functions:

• Perform and assist with medical billing and claiming activities, including any data entry, to obtain from liable payers reimbursement for services provided by state-operated facilities and community-based programs.
• Meet all claiming, eligibility and accounts receivable deadlines.
• Identify and coordinate access to Medicaid (MassHealth), Medicare and commercial health care insurance, Social Security Administration and other programs and benefits.
• Outreach to, proactively support and work with clients, clients' families, guardians and representatives to complete and process applications, forms and other documents required to determine, redetermine, validate, reinstate and maintain health care coverage and related benefits.
• Perform and assist with broad spectrum of business services or specific services and focused activities.
• Review and analyze data, maintain and update spreadsheets, databases and systems and resolve discrepancies.
• Provide internal and external customers with professional customer service including responding to and following up on inquiries.
• Write, review, prepare and maintain business documents including reports, contracts, manuals, procedures and presentations.
• Participate in professional training and cross-training activities to enhance performance and skills.
• Participate in continuous quality improvement initiatives and projects. Foster compliance with state and federal rules and regulations.
• Work independently and as a team member and leader.
• Preserve confidential, protected health and personally identifiable information and files.
• Perform other duties and special projects as required.

Qualifications

Required Qualifications:

• Associate's degree or equivalent experience.
• 1-3 years of related experience
• Familiarity with database and spreadsheet applications such as Microsoft Office including Word, Excel, Teams and One Drive
• Ability to communicate effectively
• Ability to adapt and change direction in response to changes in the business environment.

Preferred Qualifications:

• Medical billing or health care insurance experience
• Basic Knowledge of accounting
• Knowledge of state and federal rules and regulations related to health care finance
• Knowledge of state and federal information systems such as HUB, MA21, MMIS and Mosaic

Additional Information

The PPR Specialist is responsible for performing Charges for Care and Benefit Eligibility functions for the Department of Developmental Services (DDS), Southeast Region. This role supports individuals residing in State-Operated Homes by ensuring the accurate administration of room and board billing, reimbursement, and benefit eligibility processes. The PPR Specialist works collaboratively with internal and external stakeholders to maintain compliance, promote timely revenue collection, and ensure clients receive appropriate benefits and services.

This position is based at the Wrentham Developmental Center on Emerald Street in Wrentham and follows a hybrid work schedule that combines in-office and remote work. Minimal travel may be required to attend meetings and other work-related activities.