Position Summary The Claims Senior Representative Refunds is responsible for researching, reviewing, and processing patient and insurance refund requests resulting from overpayments, duplicate payments, coordination of benefits adjustments, claim reprocessing, and billing corrections. The position works closely with Revenue Cycle, Finance, Customer Service, Account Management, and Health Plan partners to ensure refunds are processed accurately, timely, and in compliance with internal policies, payer requirements, and regulatory guidelines. The ideal candidate possesses strong analytical skills, a thorough understanding of the healthcare claims lifecycle, and experience managing patient and payer overpayment scenarios. Essential Job Functions - Review and process patient and insurance refund requests in accordance with company policy and regulatory requirements.
- Research patient accounts to determine refund eligibility and validate overpayment balances.
- Analyze remittance advice, EOBs, adjustment activity, and payment history to identify refund opportunities.
- Investigate and resolve overpayments, duplicate payments, coordination of benefits issues, and payment posting discrepancies.
- Process payer refund requests, takebacks, recoupments, and offset requests.
- Perform account audits to ensure billing accuracy and identify improper charges or payment variances.
- Maintain refund work queues, shared mailboxes, and ticketing systems within established service levels.
- Create and document account adjustments, refunds, write-offs, and corrective actions.
- Work with Finance and Treasury teams to reconcile refund transactions and outstanding liabilities.
- Monitor aging refund balances and ensure timely resolution.
- Respond to internal and external inquiries regarding refund status and payment research.
- Escalate complex refund issues, system defects, or compliance concerns to leadership.
- Assist with monthly reconciliation activities, audit requests, and reporting.
- Identify trends and process improvement opportunities related to refunds and overpayments.
- Maintain detailed documentation supporting all refund decisions and transactions.
- Participate in testing and validation of billing, refund, and payment system enhancements.
- Provide training and guidance to team members regarding refund processes and best practices.
- Perform additional duties and special projects as assigned.
Required Qualifications - High school diploma or equivalent required.
- Associate or bachelor s degree in business, Finance, Healthcare Administration, or related field preferred.
- Minimum 3-5 years of healthcare Revenue Cycle Management experience.
- Minimum 2 years of experience in refunds, overpayments, cash posting, AR follow-up, or claims processing.
- Strong knowledge of commercial, Medicare, Medicaid, and employer-sponsored health plans.
- Ability to interpret EOBs, ERAs, payer correspondence, and refund requests.
- Experience working within EMR/PM systems such as Athenahealth preferred.
- Proficiency in Microsoft Excel, Word, and Outlook.
This position includes fiduciary duty or access to financial systems: Yes
3 Non-Negotiable Skills:
- Familiar with patient refund process (Preferred)
- Some Experience with Excel
- Attention to detail |