Become A Reimbursement Specialist

* Duties may include, but not limited to all or some of the following)
* Accurately interprets patient insurance, prescription and other health-related documentation
* Conducts medical and pharmacy benefit insurance verifications and investigations for commercial and government payors
* Communicates with insurance companies, patients, providers and prescribers to coordinate reimbursement and access solution
* Researches available alternative funding options to reduce patient’s financial burden
* Handles high call volumes in a call-center environment
* Communicates with internal and external departments to facilitate coordination of care
* Reports Adverse Events (AE) and Product Quality Complaints (PQC), as required and as per policy
* Strictly adheres to Standard Operating Procedures (SOPs)
* Analyzes records to transcribe appropriate ICD
* ICD-10, CPT, HCPCS codes
* Validates and enters prescription orders
* Completes casework in a timely manner with consistent follow-up as the accountable case manager
* Maintains patient confidentiality
* Advocates on behalf of the patient to problem-solve reimbursement and access issues
* Understands prescription drug benefit management techniques including Formularies, Prior Authorizations, etc.
* Performs clerical and administrative functions such as mailing and faxing correspondence, data entry, scheduling, etc.
* Validate licensed practitioners

* Follows up on invoices submitted to ensure prompt and timely payment and escalates issues as necessary.
* Evaluates payments/denials received for correctness and ensures that they are applied appropriately.
* Identifies bad debt write-offs and A/R adjustments.
* Initiates write-off and adjustments in accordance with policies and procedures.
* Ensures that secondary bills and patient invoices are accurately generated and submitted on a timely basis.
* Identifies any overpayments and/or duplicate payments, and investigates and resolves.
* Processes refund requests, in accordance with policies and procedures.
* Adheres to Regulatory / Payor Guidelines and policies & procedures.
* Supervisory Responsibilities:
* None

* Demonstrates through behavior Florida Hospital’s Core Values of Integrity, Compassion, Balance, Excellence, Stewardship and Teamwork as outlined in the organization’s Performance Excellence Program
* Works with Insurance payors to ensure proper reimbursement on patient accounts to expedite resolution.
* Processes administrative appeals, refunds, reinstatements and rejections of insurance claims.
* Completes account follow up daily, maintaining established goal (s), and notifies Lead Rep, when necessary, of issues preventing achievement of such goal(s).
* Analyzes daily correspondence (denials, underpayments) to appropriately resolve issues.
* Responds to written correspondence received from Payor and/or Patients.
* Assists Customer Service area with patient concerns/questions to ensure prompt and accurate resolution is achieved.
* Analyzes previous account documentation, in order to determine appropriate action(s) necessary to resolve each assigned account.
* Initiates next billing, follow-up and/or collection step(s), not limited to calling Patients, Insurers or Employers, as appropriate.
* Remits initial or secondary bills to insurance companies.
* Documents the billing, follow-up and/or collection step(s) that are and all measures to resolve assigned accounts, including escalation to Supervisor if necessary.
* Remains in consistent daily communication with Insurance Reimbursement Supervisor and Lead Insurance Reimbursement Specialist regarding all aspects of assigned projects.
* Adheres to HIPAA regulations by verifying pertinent information to determine caller authorization level receiving information on account
* If you want to be a part of a team that is dedicated to delivering the highest quality in patient care, we invite you to explore the Insurance Reimbursement Specialist opportunity with Maitland and apply online today.
* Job Keywords:
* Billing, Patient Financial Services, Insurance Reimbursement

* Coordinates the Vanderbilt billing process
* Accurately, efficiently and timely processing of claims, payments, refunds, denials, unpaid patient and insurance balances
* Accesses and takes corrective action, if necessary, of incoming financial data.
* Works account referred for follow-up in an accurate and timely manner
* Gives feedback to requesting party in a timely manner
* Provides accurate account maintenance and documentation sufficient for audit controls
* Maintains appropriate batching of financial transactions for imaging and audit purposes.
* Account documentations are timely and contain complete information
* Serves as liaison with insurance companies, third party payors, and administrative personnel, including Contracts Administration and customers.
* All necessary entities contacted to bring resolution to matter.
* Appropriately contacts proper entities with issues concerning their areas.
* Properly alert all areas affected by a particular situation
* Analyze incoming financial data to identify patterns from insurance carriers and/or other entities resulting in erroneous or no reimbursement
* Entire account audit performed
* Payer pattern(s) identified and addressed with payer
* Resolution of any issue(s) resulting in delayed or erroneous reimbursement
* Obtained proper payer reimbursement
* Identification of improper CPT 4/ICD 9 usage (APC, DRG) resulting in denial or erroneous reimbursement.
* Recognizes coding errors
* Has basic coding knowledge
* Utilizes coding software package
* Ability to identify improper coding linkage errors
* Ability to identify improper use of or needed modifiers
* Identify payers with/without contracts; interpret payer fee schedule on expected reimbursement
* Can correctly identify payers with whom Vanderbilt is contracted
* Identify erroneous reimbursement and adjustments according to fee schedule
* Address expected reimbursement guidelines to carrier, seeking further payment.
* Differential between payer edit errors and account specific payment error
* Prepare and maintain complex reports and records requiring the identification of sources, compilation, analysis and evaluation of data
* Ability to maintain data in appropriate source, i.e. spreadsheet.
* Can manipulate data, enabling the identification of patterns by multiple fields, i.e., CPT 4 codes, ICD 9 codes, payer
* Presentation of projects in appropriate format.
* Provide analytical and administrative support to special projects
* Assist supervisors with complex projects, i.e. audits, compliance issues.
* Update departmental policy and procedures
* In absence of supervisor, organize, schedule and monitor daily operations.
* Ability to apply managerial discretion when adjusting or approving adjustments to alter the financial balance of a patient account.
* Must meet productivity standards specific to the work unit guidelines
* TECHNICAL CAPABILITIES:
* CORE ACCOUNTABILITIES:
* CORE CAPABILITIES:
* High School Diploma or GED and 5 years relevant experience
* Licensure, Certification, and/or Registration (LCR

* Adherence to Health Information Management (HIM) Coding policies.
* Adherence to The Joint Commission (TJC) and other third party documentation guidelines in an effort to continually improve coding quality and accuracy.
* Interprets and applies American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal, secondary diagnoses and procedures.
* Responsibility for maintaining coding certification and referencing current ICD
* coding guidelines and regulatory changes.
* Contacts the appropriate charging department for assistance in obtaining physician clarification of diagnoses and/or procedures.
* Participates in performance improvement initiatives as assigned.
* This position is integral to the collaboration and teamwork with Clinical Documentation Improvement Department and interacts with health care givers as a team member striving to achieve quality patient care at Renown Health.
* The incumbent must consistently meet or exceed productivity and quality standards as defined by the HIM Coding Leadership.
* Telecommute is allowed with approval from HIM Management.
* KNOWLEDGE