Reimbursement Recovery Specialist

Summary

The Reimbursement Recovery Specialist is responsible for securing the payment of medical claims in a timely and efficient manner in order to secure the financial health of H. Lee Moffitt Cancer Center. This includes analyzing, identifying and resolving barriers, monitoring unpaid claims, analyzing denied, pended or underpaid claims, appealing administrative denials, resolving administrative and clinically appealed claims and, when applicable, reviewing credit balances and payer payments for the Accounts Receivable Team.

The specialist reviews all payer refund requests for appropriateness and appeals/contests when applicable. This position protects and defends contract terms, Letters of Agreement and Rate Agreements.

• Takes steps to secure payment on aged receivables by making outbound calls, utilizes payer portals, payer website or 277 Transmission Code Sets for account status.
• Takes appropriate action, when necessary, including submitting required documents, i.e., itemization of charges, medical records, on claims pended for payment.
• Appeals all administrative denials, submits Reconciliation forms, etc., on denied claims.
• Analyze denied or partially paid claims and determine steps to achieve appropriate reimbursement.

• Works all Worklists (WLs) throughout each day, every day.
• Demonstrates proper sorting of WLs.
• Responds to written correspondence received from payer and/or patients.
• Reviews payer refund requests, contesting and/or appealing those that are not appropriate.
• Is responsible to stay current on all active, assigned accounts which prevents abandonment, uncollected account receivables.
• Ensures Transfer List is current and up-to-date with accounts being worked a minimum of every 30 days until resolved.
• Ensures follow-up and follow through are met consistently, per protocol, on outstanding accounts and escalated when applicable.
• Ensures collection and documentation are correct and appropriate action, if any, taken place a documented.
• Ensures universal abbreviates and appropriate terms are used and not lengthy, yet to the point.
• Reviews contracts to determine if payments are appropriate; defends contract terms, Letters of Agreement and Rate Agreements.
• For BMT Collectors, promptly reviews credit balances from the AR Team for possible adjustment or refund.

• Meets or exceeds established productivity goals; notifies Supervisor, when necessary, of issues preventing achievement of such goal(s) per departmental Operational Guidelines.
• Demonstrates proactiveness when not meeting Mid-Month Productivity Goals Based on Hour Worked or Monthly.
• Productivity Goals Based on Hours Worked by reaching out for re-education/game plan to get back on track.

• Minimum of three (3) years recent medical collections experience in a hospital or large group practice setting. For a large group setting, primary responsibility is that of insurance collections and follow-up and/or Denials Management.

• For the Commercial and Aetna/Blue Cross/United Teams, experience with commercial payors preferred, including eligibility inquiries and Denials Management. Billing and claim submission experience, preferably on a UB04, is a plus.
• For the Medicare and Medicaid Team, experience with Medicare, Medicare Advantage and Medicaid preferred, including eligibility inquiries via DDE or SPOT and Denials Management. Billing and claim submission experience, preferably on a UB04, is a plus.

• High School Diploma/GED

• Associate’s Degree within Healthcare Administration, Accounting, Business, Finance or other relevant discipline