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Sr. Reimbursement Specialist
4 months ago
POSITION SUMMARY:
Determine eligibility and benefits, answer billing questions, and obtain authorizations, and predeterminations. Process insurance verification requests and secure prior authorization approvals for eligibility and benefit coverage. Research and answer questions as it relates to medical verifications of insurance policies, coding, billing, and claims. Conduct effective communications with the physician's office, Health Plan, and the Company's sales team. Assist in new hire onboarding training and help junior team members as needed, with a focus on accuracy and efficiency in processes and results. Adhere to all applicable policies, procedures, processes and systems in order to obtain accurate coverage information and optimize the maximum reimbursement levels.
We are excited to add a Sr. Reimbursement Specialist to our team The position will pay between $57-70k base based on previous relevant experience, educational credentials, and location.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
* Receive and process assigned clinical authorizations and insurance verification requests (IVR's) from data intake team
* Review IVR and correct data entry errors and omissions (e.g. incorrect Health Plan, missing information, etc.)
* Determine if payer already in database; if not, research payer on website to obtain demographic information and add new payer information and their processes to database
* Obtain benefit coverage levels and prior authorization requirements from Health Plan, submit required paperwork, and follow-up on coverage requests and prior authorizations
* Enter coverage levels and/or prior authorization requirements for assigned accounts in database
* Research and review electronically stored health policy notes and historical reimbursements, coverage information provided by Health Plan, and procedural information (e.g. diagnosis, product, place of service, etc.) from provider to aid in making accurate coverage determinations
* Analyze and interpret collected data, obtain additional information as needed, make coverage determination, and notify provider of decision
* Collaborate with sales and field reimbursement teams to get complete and correct information to process IVR/s
* Research and/or respond to escalated, moderately complex questions from junior level members, as well as from physicians, hospitals, outpatient facilities/ambulatory care centers, etc. regarding billing, coding procedures, and processes
* Review and complete daily pending case reports to ensure prompt processing and closure of IVR's and authorization requests
* Identify and escalate issues as they may arise throughout the process; report IVR quality issues in an effort to minimize errors in processing and coverage determinations
* Report changes/issues in coverage/reimbursement trends to management
* Identify and recommend system and/or process changes to improve efficiencies
* Follow HIPAA policies and procedures to ensure compliance
* Assist and participate in project workgroup(s) with various departments regarding needed improvements to database (Alfresco)
* Assist with new hire onboarding training; provide ongoing assistance to junior level team members
* Identify potential team member training needs/issues; conduct regular team training meetings
* Act as back-up to supervisor when they are unavailable or out of the office
PROBLEM SOLVING:
* Performs full range of standard professional level work that typically requires processing and interpreting, more complex, less clearly defined issues. Identifies problems and possible solutions and takes appropriate action to resolve
* Demonstrates skill in data analysis techniques by resolving missing/incomplete information, inconsistencies/anomalies in more complex research/data
DECISION MAKING/SCOPE OF AUTHORITY:
* Nature of work requires increasing independence; receives guidance only on unusual complex problems or issues
* Work review typically involves periodic review of output by supervisor and/or direct "customers" of the process
* Makes benefit coverage decisions after researching, collecting, and reviewing all relevant information, on a case-by-case basis. Accurate coverage decisions are critical; inaccurate coverage decisions can result in the loss of customers, and therefore, have an adverse financial impact to the Company.
SPAN OF CONTROL/COMPLEXITY:
* Fully competent and productive professional contributor, working independently on larger, moderately complex projects/assignments that have direct impact on department results
EDUCATION/EXPERIENCE:
* BS/BA in related discipline
* 2-5 years of experience in related field with 1-3 years of progressive responsible positions, or verifiable ability
OR
* MS/MA and 1-3 years of experience in related field. Certification is required in some areas
* 3-5 years of experience in insurance verification, billing/claims processing, data processing
* Thorough knowledge of medical coding including ICD10, CPT and HCPCS codes
* Thorough understanding of Medicare, Medicaid, and Commercial and health plans
* Thorough understanding of medical management, health insurance concepts, information systems
* Excellent understanding of HIPAA rules
SKILLS/COMPETENCIES:
* Excellent oral, written, and interpersonal communication skills
* Ability to interact with all levels of management, both internal and external, third party payers, and customers; with a focus on customer service
* Proficient in Microsoft Office (Excel, Word, etc.)
* Organized, flexible, and able to multi-task while maintaining a high level of efficiency and attention to detail
* Excellent analytical, problem solving, and trouble shooting skills
* Ability to make quick, sound decisions based on policy, past practices, and experience
WORK ENVIRONMENT:
The work is typically performed in a normal office environment. Will be assigned a pre-defined work shift based on current business needs.
Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to, or requirements for, this job at any time.
