Reimbursement Specialist

General Summary/Overview:
Reports to the Medical Billing Manager. Responsible for implementing and maintaining close relationships with HMA providers and managers; promoting satisfaction with billing services, providing a communication link between the sites and the billing office, and assists the providers and staff to maximize reimbursement. Performs in accordance with the facility's policies and procedures. Follows the facility's standards for ethical business conduct. Conducts self as a positive role model and team member. Participates in facility committees, meetings, in-services, and activities.
Principal Duties and Responsibilities:
1. Provides, reconciles and prepares reimbursement/denial reports.
2. Reviews Insurance Contracts as well as keeps in contact with third-party representatives and researches specific questions regarding third parties allowable rates.
3. Perform routine audits of third-party explanation of benefits forms and remittance advices.
4. Communicates trends and reimbursement/denial findings within the billing department and individual providers.
5. Researches and updates the computer system with the correct quarterly allowable changes provided by the Insurance Carriers.
6. Reviews the Redbook's Average Wholesale prices and invoices on a regular basis.
7. Understands and communicates to HMA providers and staff and billing office personnel third-party payment rules.
8. Works closely with patient accounts to ensure expected reimbursement is achieved.
9. Assists the appeals team to identify appropriate medical necessity appeals and works with the appeals team and the department to provide necessary documentation.
10. Works with the appeals team to identify trends in appeals and adjustments, researching problems and recommending solutions that will maximize reimbursement.
11. Continually educate and inform Managers and providers of federal, state and third-party rules for services.
12. Develops and/or facilitates education sessions with providers and managers regarding specific rules regarding coding and billing of services.
13. Assist the HMA providers and staff to develop and maintain front end billing communications that will enhance reimbursement.
14. Perform other duties and responsibilities as assigned
Associate's degree or equivalent plus 5 years experience hands-on provider billing.
Skills and Abilities Required:
Must possess excellent written and communication skills. Have an ability to effectively interact with staff and providers at all levels of the organization to facilitate solutions to operational problems. Computer literate in Microsoft Office products including strong working knowledge of Excel. Working knowledge of current third-party reimbursement regulations. Working knowledge of current CPT and ICD-9 coding.
Working Conditions:
The work environment is one of a typical office work environment. Extensive computer work is an essential portion of the working conditions and necessary for job performance. While performing the duties of this job the employee is frequently required to sit, walk; stand; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and talk or hear. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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