Reimbursement Specialist

Summary

The Reimbursement Specialist is responsible for assisting the Reimbursement Supervisor and fellow staff in following up with commercial and governmental payers to ensure timely resolution of billing issues and accurate claims reimbursement. This individual is also responsible for collaborating with other departments to drive payer collections, communicating process issues and improvements to the supervisor and training new staff.

Job Duties & Responsibilities

• Identifies and analyzes underpayments to determine the reasons for discrepancies and processes denials and appeals; examines claims to ensure payers are complying with contractual agreements.
• Reviews posted payments to ensure accuracy; analyzes explanation of benefits to ensure proper reimbursement.
• Communicates directly with payers to follow up on outstanding claims and resolve payment variances, responds to payer inquiries and concerns, and works to develop and maintain positive relationships with payers.
• Monitors and reviews denial reason codes and underpayments to identify root causes; works with payer contracting and other areas of the revenue cycle if necessary to resolve issues.
• Analyzes data to track collection efforts, identify trends, and provide team with updates and ideas for improvement.
• Monitors payer files for accuracy, ensures payer documentation is completed by follow up staff, and assists in updating files with pertinent information as necessary.
• Assists other follow up staff in identifying high-risk accounts and prioritizing follow up efforts.
• Helps to work and resolve accounts from other staff members workloads to prevent backlogs and fills in as needed for absent staff.
• Maintains superior understanding of claims management, third party payer guidelines, state and federal regulations, and all other functions of the job; educates and trains other follow-up staff as needed.
• Collaborates with other departments to identify best-practice collections strategies, align goals, and improve collections.
• Maintains compliance with HIPAA guidelines and ensures staff maintain discretion when handling patient information.

Education/Training Requirements

• High school diploma or equivalent required
• Associate or bachelor's degree preferred
• Minimum of three years of relevant experience in mental health or medical insurance billing and/or collections required
• Minimum of three years working in Patient Financial Services encompassing all levels of care and UB04 and HCFA 1500 claims billing required
• Demonstrated knowledge of and experience with third-party payer guidelines, reimbursement, follow-up, and collections
• Demonstrated knowledge of claims review and analysis; ICD-10, CPT, and HCPCS coding; and medical terminology
• Effective communication, leadership, organizational, and problem-solving skills
• Ability to manage multiple tasks and projects simultaneously
• Ability to analyze data, identify improvement, and implement change
• Strong interpersonal and customer service skills
• Proficiency with Microsoft Word, Excel, Outlook, Teams, OneNote and Oracle Health Patient Accounting systems
• Ability to work quickly and effectively in a fast-paced detail-oriented environment while adhering to deadlines