Description

SUMMARY/OBJECTIVE:

The Reimbursement Specialist is responsible for all aspects of revenue reporting, claims billing, and accounts receivable management for their assigned programs. This includes maintaining accurate records of claims payments, reconciling accounts receivable, and supporting peers in billing and collections for other service lines as needed. As a key member of the Revenue Cycle team, the Reimbursement Specialist facilitates the full claims process, from accurate and timely creation through follow-up, resolution, and posting of payments. The role requires regular collaboration with department directors, providers, insurance representatives, and clients to address inquiries and ensure prompt reimbursement. The incumbent also contributes to the clarification, development, and implementation of process improvements to maximize revenue and operational efficiency. The Reimbursement Specialist is expected to take initiative, ensure compliance with policy, and provide exceptional administrative and client service support across all functions of the reimbursement process..

KEY FOCUS AREAS:

• World Class Customer Service
• Knowledge of claims review, analysis, accounting procedures and quality assurance
• Accurate and Timely Claims Submissions
• Advanced Excel spreadsheet capability

Essential Functions (Job Duties)

• • Prepares and submits clean claims to insurance payers via manual posting of claim payments, as well as importing/uploading electronic 837/835 files.

  • Follows billing guidelines and legal requirements to ensure compliance with federal and state regulations.
  • Responds to account inquiries from clients, payers, providers, and/or other staff as requested.
  • Identifies and resolves client/insurance billing and payment issues.
  • Responsible for reviewing accounts which have been denied or underpaid by third party payers
   

  and resolves the issues resulting in denial/underpayment and handles formal appeals, if necessary.

• Works closely with team members regarding claim appeals, denials, resolution, and education.
• Performs and monitors all steps in the billing processes to ensure maximum reimbursement from clients, government and commercial payers as well as from special billing arrangements.
• Understands Medicare, Medicaid and other commercial payer rules and regulations applicable to billing.
• Updates senior leadership, department directors, staff, clients, and mangers of changes, as appropriate.
• Responsible for reviewing and implementing changes from payer bulletins.
• Uses online healthcare databases and other resources for verification and claim status.
• Delivers the highest quality service to internal and external customers.
• Must be comfortable working tight deadlines, have the ability to analyze and trouble shoot billing concerns and communicate concerns with leadership.
• Ability to maintain repour and communications with internal departments.
• Assists other members of the team with projects as needed.
• Maintains strictest confidentiality; adheres to all HIPAA guidelines/regulations.
• Other duties as assigned by management.

Qualifications

Competencies

• • Confidentiality

  • Crisis Management - Is able to multi-task in a highly time sensitive environment and is able to switch priorities with short notice.
  • Customer/Client Focus - Demonstrates a high degree of courtesy, efficiency and professionalism when communicating with colleagues, internal and external customers. Must have a flexible approach to situations and be willing and able to adapt as processes and systems change. Tailors’ communication to non-technical associates to ensure a clear understanding of project updates and modifications.
  • Problem Solving/Analysis - Is able to use logic to solve difficult problems with effective solutions; thinks outside the box and probes all fruitful sources for answers; is analytical, looks beyond the obvious and does not stop at the first answers. Does this while working within processes and compliance requirements.
  • Well Organized and Detail Oriented
  • Solution Based Approach - Must be focused, self-directed, organized, and have demonstrated problem- solving abilities.
  • Excellent Interpersonal Skills - Relates well to all kinds of people inside and outside the organization.
   

  builds appropriate rapport and constructive relationships; uses diplomacy, professionalism and tact; can diffuse high-tension situations comfortably. Excellent oral and written communication skills. Able to work both independently and as part of a team.

• Complies with all CAI, state and federal policies and procedures
• Microsoft Office Applications, especially Excel, and ability to learn other software and technology requirements, incorporates technical knowledge and data analysis to reinforce business requirements and assessing project scope and requirements while remaining sensitive to deadlines. Picks up on technical things quickly; can adapt to change and enjoys learning a new industry.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Position Type/Expected Hours of Work

This is a full-time position. 40 hours per week.

Workweek schedule: Typical work week is Monday through Friday, 8 a.m. – 4 p.m.;

Hours and schedules may vary depending on Company need and workload. Employees will be given as much notice as possible when such changes occur.

Travel

The Reimbursement Specialist work hybrid under the direction of Revenue Management who may be asked to monitor other regional locations on an ad hoc basis, depending upon need.

Required Education and Experience

1. Associate degree desired, but not required.
2. Minimum 2-years of experience in a customer service focused environment; preferably in a behavioral healthcare services environment.
3. Highly computer literate and proficient in the Microsoft Office Suite of Products. (Word, Excel, Power Point).
4. Proven ability to manage multiple work functions in a high-volume demanding setting.
5. Must have strong knowledge of all guidelines for ICD-10, CPT/HCPCS codes, medical terminology, and billing processes.
6. Knowledge of Explanation of Benefits (EOBs), Electronic Funds Transfer (EFTs) and Electronic Remittance Advice (ERAs).
7. Preferred knowledge of Medical Billing/EHR (Electronic Health Records) systems preferably Medisked, Accumed, and/or NetSmart.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.