Specialist-Reimbursement Lead

Job Summary

The main objective of this role is to ensure correct processing of all insurance claims of all infusion pharmacy. In addition to interpreting and implementing specified insurance billing guidelines, this role coordinates all facets for insurance billing, credits, and collection of account receivables. Moreover, it ensures that duties are completed accurately and timely while acting as a team player for optimum office flow and excellent patient service.

• Responsible for clear, detailed communication with the clinical and billing staff along with payers and clients regarding various insurance and payment related issues
• Bill and submit claims for all insurance companies according to payer specific guidelines and established procedures and workflow
• Be knowledgeable of payer updates as it relates to bundling and unbundling charges, medical necessity and general coding specifications
• Review and process adjustments as needed for accounts to avoid claim release if not needed but also recognize and resolve credit balances as needed
• Able to resolve all front-end claim edits and clearinghouse returns so that claims can be resubmitted in a timely manner to payers/insurance carriers
• Responsible daily for the correction of primary/secondary rejected claims, the resubmission of rejected claims along with resolution of all delinquent insurance claims on patient accounts, per guidelines, to secure payment
• Completes all assigned goals
• Assists the Manager with other functions

• Strong verbal and written skills
• Must be able to work independently within assigned guidelines
• Shows initiative and enjoys working as a team in a fast pace and stressful environment with strong attention to details
• At least one year in a hospital/physician business office setting

• Experience in medical billing, previous employment in the insurance industry, or professional certification; three to five years preferred

• Skill in communicating clearly and effectively using standard English in written, oral and verbal format to achieve high productivity and efficiency
• Skill to write legibly and record information accurately as necessary to perform job duties

• B.S. Degree or one to 3 years medical claims billing or processing with some college, vocational or certification in the insurance industry

• PC
  
  Skills:
  
  Keyboarding 35-50 words per minute

• Experience with MS Word, Excel and ability to learn new computer programs

• Ability to read, understand, interpret and resolve payer front end denials
• Ability to research payer regulations and determine appropriate claim submissions
• Ability to utilize multiple patient accounting and billing applications including but not limited to connect systems, claims clearing house systems, payer systems, internet
• Ability to interface with staff at insurance carriers and hospital personnel
• Ability to read, write and understand documents, correspondence and memos
• Ability to effectively present information one-to-one and in group situations to customers, clients, and other employees in the organization
• Critical Thinking Skills Required
• Effective PC Skills Preferred/Desired
• Knowledge of ICD-9/ICD-10, CPT and HCPCS codes, Compliance, OSHA, and HIPPA regulations

Seniority level:
Entry level.

Employment type:

Other. Job function:
Information Technology. Industries:
Hospitals and Health Care.