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Reimbursement Representative

Alura Workforce Solutions

Laguna Hills, CA

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JOB DETAILS
SKILLS
Accounts Receivable, Analysis Skills, Billing, CPR Certification, Call Centers, Centers for Medicare and Medicaid Services (CMS), Claims Processing, Clinical Study Publications, Co-Payments, Contract Review, Corporate Policies, Credit and Collections, Current Procedural Terminology (CPT), Customer Support/Service, Detail Oriented, Dialysis, Fee Schedule, Healthcare Reimbursement, ICD-10, Insurance, Insurance Claims, Insurance Regulations, Maintain Compliance, Managed Care, Medical Billing, Medical Office, Medical Terminology, Medical Treatment, Microsoft Excel, Microsoft Outlook, Microsoft Word, Oncology, Pharmacy, Regulations, Reimbursement, Telephone Skills, Third-Party Payer, Time Management
LOCATION
Laguna Hills, CA
POSTED
30+ days ago
POSITION
Reimbursement Specialist llI
Oncology / Specialty Pharmacy

SUMMARY
We are seeking a highly skilled Reimbursement Specialist to join our dynamic team. The ideal candidate will be responsible for ensuring accurate and timely collections to maximize reimbursement experience. This role is essential in ensuring accurate and timely collections and maximizing reimbursement through effective interactions with third-party payers, insurance plans, and patients. The candidate will possess strong analytical skills, be detail-oriented, and excel in submitting claims, appeals, and resolving discrepancies with minimal supervision.

DESCRIPTION
  • Reviews patient inventory of assigned accounts
  • Collects on all open AR inventory to ensure reimbursements are received within 60 days of billed date
  • Work on all correspondences assigned before due dates
  • Reviews contracts and fee schedules to ensure accurate reimbursements
  • Correlating insurance coverage with services to be provided
  • Preparation and review of insurance claims
  • In-depth understanding of healthcare billing and coding processes
  • Navigate complicated insurance policies and regulations
  • Evaluates payments received to ensure that reimbursement received is accurate
  • Reviews accuracy of claims submitted and communicates to team members and management on any process inefficiencies and billing errors resulting in claim denials and underpayments
  • Quarterly audits and reviews on open inventory
  • Verifies newly submitted claims status to ensure that claims are on file with insurance, in process, and hold payers accountable for accurate and timely reimbursement
  • Ensures that all Copay Assistant claims are billed within timely to the appropriate Foundation
  • Collaborate with other departments to ensure all supporting documents are on file to support our services billed.
  • Follow up on invoices submitted to ensure prompt and timely payment.
  • Answer incoming calls from the call center que and transfer to the appropriate department.
  • Reviews accuracy of claim payments received from payers and patients
  • Identify and communicate to the management team in a timely manner on inadequate reimbursement rates that may require a pharmacy transfer
  • Submits appeals and pursues additional payments on any medical claims denied in error or paid less than the expected reasonable maximum allowable rate for the procedure codes submitted and level of patient's benefit coverage
  • Submits letter of negotiations and obtain payment resolutions from claim payers
  • Performs collections on patient balances ensuring maximum reimbursement for all services provided
  • Ensures submission of complete and appropriate clinical documentation when justifying claims medical necessity
  • Independently perform claims follow-up and collections activities such as resolving claims denials and rejections through claim resubmissions, corrected claims and appeals in compliance with Billing Department's approved reimbursement strategies in a timely manner
  • Effectively review and interpret benefits details and Identify and communicate on any inaccuracies in benefit details affecting claims reimbursement
  • Document detailed claim status on each patient's account (new or otherwise) accurately and in a timely manner
  • Creates and utilizes reminders and follow up reports to ensure completion of any incomplete or pending activities
  • Escalates to management on any unresolved claim issues after proper claim resolution attempts that have been made
  • Maintains a positive DSO on assigned account inventory
  • Provides the highest level of customer service in answering patient phone calls and resolve patients' questions and/or billing issues, as well as communicate with doctors' offices and their staff
  • Identifies and communicates to the management team on any incomplete or inaccurate billing related databases resulting in billing errors and process delays in a timely manner
  • Assists in account collections activities as needed.
  • Ensures compliance with all payer rules, regulations along with company policies & procedures.
  • Perform other duties assigned by management
REQUIREMENTS
  • Minimum of 3 years of hands-on experience in medical collections and reimbursement experience.
  • Reimbursement experience in specialty pharmacy, home infusion, oncology, dialysis or out-of-network is highly preferred 
  • In depth Knowledge of managed care, commercial insurance, ICD-10, CPT, HCPC codes, J billing codes, and medical terminology, along with CMS HCFA 1500 forms & Electronic Billing.
  • Experience with Benefit Investigation and Patient Responsibility Agreements.
  • Experience with automated billing systems, CPR+ is preferred.
  • Advanced proficiency in Microsoft Word, Excel, and Outlook.
ADDITIONAL INFORMATION
  • On-Site: (Laguna Hills, CA)
  • Hours: Monday - Friday, 8:30 am - 5:00 pm
  • Direct Placement, Benefited Role

About the Company

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Alura Workforce Solutions