Reimbursement Specialist - Healthcare determines the extent to which patients' insurance covers their treatments. Reviews appropriateness of CPT-4/ICD-10 coding and determines if care provided corresponds to the charges submitted. Being a Reimbursement Specialist - Healthcare ensures compliance with Federal and State regulations and company policies that govern Medicare and state payment systems. May assist in identifying fraudulent non-plan billing practices and assists the legal department with litigation preparation. Additionally, Reimbursement Specialist - Healthcare may require a bachelor's degree. Typically reports to a supervisor or manager. Typically requires Certified Professional Coder (CPC) from AAPC or AHIMA. The Reimbursement Specialist - Healthcare gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Reimbursement Specialist - Healthcare typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
JOB PURPOSE OR MISSION
Manages and coordinates the functions and activities related to General Health System governmental reimbursement.
PERFORMANCE CRITERIA
CRITERIA A: Everyday Excellence Values - Employee demonstrates Everyday Excellence values in the day-to-day performance of their job.
PERFORMANCE STANDARDS:
CRITERIA B: Corporate Compliance - Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines and the GHS Corporate Compliance Guidelines.
PERFORMANCE STANDARDS
CRITERIA C: Personal Achievement - Employee demonstrates initiative in achieving work goals and meeting personal objectives.
PERFORMANCE STANDARDS
CRITERIA D: Performance Improvement - Employee actively participates in Performance Improvement activities and incorporates quality improvement standards in his/her job performance.
PERFORMANCE STANDARDS
CRITERIA E: Cost Management - Employee demonstrates effective cost management practices.
PERFORMANCE STANDARDS
CRITERIA F: Patient & Employee Safety - Employee actively participates in and demonstrates effective patient and employee safety practices.
PERFORMANCE STANDARDS
JOB FUNCTIONS
ESSENTIAL JOB FUNCTIONS include, but are not limited to:
1. Ensures accurate and timely completion and settlement of all required cost reports.
PERFORMANCE STANDARDS:
2. Creates and coordinates all information-gathering processes related to cost report completion and related audits.
PERFORMANCE STANDARDS:
3. Ensures accurate and timely production of governmental contractual allowance estimates for internal financial reports.
PERFORMANCE STANDARDS:
4. Performs financial analysis/modeling to support decision-making.
PERFORMANCE STANDARDS:
5. Performs all other duties as assigned.
EXPERIENCE REQUIREMENTS
Direct healthcare reimbursement experience, or experience in healthcare finance with exposure to governmental reimbursement preferred.
EDUCATIONAL REQUIREMENTS
Bachelor’s Degree
HIPAA REQUIREMENTS
Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: medical record w/limitation to job function both paper and electronic, patient demographic information, patient financial and/or 3rd party billing information, research information.
SAFETY REQUIREMENTS
Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: incident reporting, exposure control plans, hand washing, and environment of care.
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