Medical Reimbursement Specialist

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Job Type

Full-time

Description
Job Summary

Charter Oak Health Center is seeking an Medical Reimbursement Specialist to join our team. In this role, you will be responsible for managing insurance balances. This includes following up with insurance companies and submitting appeals for any rejected or denied claims. The Specialist ensures that insurance claims are paid correctly to the organization. They manage outstanding accounts according to department standards, which may include maintaining a list of professional accounts, keeping track of payment agreements or reasons for unpaid balances, and making collection efforts. They also coordinate any adjustments, contractual allowances, or refunds as authorized. The Specialist identifies why claims are denied and stays updated on the specific policies and contracts of different insurers. An AR Denials Specialist at this level understands how to handle underpayments and credit balances effectively. This position offers an exciting opportunity to make a difference in the community while advancing your career in healthcare.

Essential Position Duties

• Identifies root causes behind insurance denials and keeps up to date with payer policies, contracts, and bulletins.
• Shares information on trends related to payer denials for specific procedures or diagnosis codes with management.
• Resolves insurance balances accurately after payments are made. This includes identifying any patient costs and ensuring accounts are correctly settled according to payment terms.
• Follows up with payers to make sure outstanding claims are resolved quickly by using phone calls, emails, faxes, or websites.
• Uses both internal and external resources to analyze patient accounts and takes action to resolve payment issues. Documents all activities according to organizational and payer policies.
• Submits Letters of Medical Necessity (LOMN) with appeals for claims that were rejected or denied.
• Continue to check accounts and escalate issues if a denial is not overturned.
• Works with the Patient Access, Medical Coding Coordinator, Patient Service Representative, and Eligibility Coordinators to resolve denials related to medical necessity, eligibility, referrals, or authorization.
• Sets follow-up actions based on how the claims are progressing and ensures clear documentation in the system.
• Works with team members on special projects to achieve timely deliverables - and communicates results effectively, while also completing other assigned tasks.

Compliance Responsibilities

• Complies with applicable legal requirements, standards, policies, and procedures, including but not limited to those within the Compliance Process, Code of Conduct, HIPAA, and Corporate Integrity Agreement (CIA).
• Participates in required orientation and training programs, as required.
• Reports concerns and suspected incidences of non-compliance in accordance with COHC Compliance Reporting Process.
• Cooperates with monitoring and audit functions and investigations.
• Participates, as requested, in process improvement responsibilities.

Requirements
Professional Experience/Educational Requirements

• High School Diploma/GED or minimum of 2 years direct experience with an Associate or Bachelor's degree from an accredited program
• Minimum of 3 years' Billing experience required in healthcare Rev Cycle with specialization in billing, account receivable follow-up, and denial management
• Two years of accounting experience, and strong knowledge of accounting theory and methods.

Certification/Licensure

• Certified Medical Biller/not required
• Certified Revenue Cycle Specialist/not required

Salary Description

$ $25.00