Reimbursement Specialist - Healthcare jobs in Wilmington, DE
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)
Recently Added Reimbursement Specialist - Healthcare jobs
Market Clinical Reimbursement Manager
- Genesis HealthCare
-
Kennett, PA
FULL_TIME
-
POSITION SUMMARY: The Case Manager is responsible to ensure the collaborative process of assessment, planning, facilitation and advocacy for options and services to meet the patient's health needs through communication and available resources to promote quality and cost-effective outcomes. The Case Manager ensures the Interdisciplinary Team implements agreed-upon, necessary services as outlined in the patient plan of care subject to contract terms and case negotiations in order to minimize overutilization or under-utilization of services and associated unreimbursed claims. He/she acts as an account liaison on Genesis' behalf with our plan providers and identifies opportunities for quality and performance improvement and communicates to
supervisor and/or Administrator. The Case Manager performs to establish productivity metrics which reflect the Case Manager's effectiveness and efficiencies in carrying out responsibilities.
RESPONSIBILITIES/ACCOUNTABILITIES:
1. Based on standard operating procedures, verifies and communicates current, accurate and complete clinical information to payor from patient Pre-Admission through Concurrent Review using standard and plan review forms to justify clinical necessity according to payor review schedule. Ensures documentation is timely, accurate and complete in PointClickCare (PCC) and field file.
2. Reviews and CRM Pre-Authorization assessment to identify costly treatments, supplies or services.
3. Negotiates for appropriate continuation of length of stay or extension of services and appropriate Level of Care (what is covered/what is not covered) and associated rates.
4. Facilitates obtaining payor authorization for recommended treatments, procedures, supplies, equipment and medications and all exclusions
5. Reviews Admission orders on all managed care patients for appropriateness. If necessary, re-negotiates Length of Service and Level of Care.
6. Communicates contract terms for patient's stay to Interdisciplinary Team, e.g. Level of Care, Length of Service, Utilization of Services, Inclusions and Exclusions, Revenue Per Day, Network Providers, Rehab Treatments.
7. Actively monitors patient's case throughout stay to ensure utilization of services are in accordance with plan of care and minimize financial risk to patient and center.
8. Acts as resource to Physicians, NPs and Treatment Team to identify alternate, costeffective treatment options
9. Liaises with appropriate staff to gain or provide information, e.g. MDS Coordinator, Unit Manager, Social Worker, Business Office, Director of Rehab.
10. Reviews NetHealth documentation and clearly document current clinical and discharge planning information sent to payer and maintain in field file
11. Actively participates in weekly Utilization Management Meeting.
12. Alerts appropriate staff and vendors of non-covered services.
13. Alerts appropriate staff when duplicate services are ordered.
14. Monitors changes in status that could lead to hospital readmission and report to nursing.
15. Identifies overuse of resources such as rehabilitation therapy, diagnostic studies, non-formulary medications and medical supplies
16. Alerts Center Designee to last covered day of service. Requests Notice of NonCoverage be delivered to patient/family for signature with copy of notification in Center Financial File.
17. Assists center in responding to denial of continued services by providing clinical information that substantiates medical necessity. Writes clinical appeals to insurance plans as needed.
18. Prepares patient's case for discharge/transition by ensuring network providers are known and securing all appropriate authorizations for a safe, coordinated discharge for patient/caregiver.
19. Assesses patient/family risk factors as it relates to resource utilization: chronicity, complications and co-morbidity and identifies barriers to a timely discharge.
20. Consults Social Worker immediately for all social, customer/family problems that are identified as barriers to a timely, appropriate discharge.
21. Maintains comprehensive case management records on all customers that reflect authorizations, extensions, levels of care, dates of service and rates approved by the payer to include name, phone and date of payer case manager's authorization.
22. Manages relationships with 3rd party payers ensuring timely responses.
23. Identifies service delivery and process improvements and communicates to the center level leadership
MCIL
Qualifications:
Graduate of an accredited School of Nursing with current LPN licensure in the
state where employment occurs or where case management is practiced contingent upon state regulations required. Certified Case Management (CCM) or related clinical certifications are also preferred.
2. Five years of recent clinical nursing experience required. Prior experience
in utilization review, case management or discharge planning required.
3. Prior experience using evidence-based clinical decision support criteria (e.g. Interqual, Milliman)
6. Experience in rehabilitation nursing, acute care and/or the insurance field
preferred. Two years full time experience in case management which includes
service to short/long term facility based clients preferred.
7. Advanced knowledge of third party reimbursement, insurance coverage and contract requirements. Other Info
Job City: Kennett Square
Requisition Number: 440653
Not Stated - 1 Day Ago
Medical Reimbursement Specialist
- GHR Search
-
Castle, DE
FULL_TIME
- POSITION SUMMARY: To perform this job successfully, and individual must be able to perform the essential functions of this position satisfactorily but are not necessarily limited to the following: Res...
- 19 Days Ago
MDS Clinical Reimbursement Coordinator -- RN
- Genesis HealthCare
-
Milford, DE
FULL_TIME
- Genesis HealthCare is one of the nation's leading providers of healthcare services from short-term to long-term care and a wide variety of living options and professional clinical services. We are cha...
- Just Posted
Clinical Reimbursement Manager/MDS Manager
- Genesis HealthCare - Kennett Square, PA
-
Kennett, PA
FULL_TIME
- Genesis HealthCare is one of the nation's leading providers of healthcare services from short-term to long-term care and a wide variety of living options and professional clinical services. We are cha...
- 1 Month Ago
Ophthalmic Technician
- Omni Eye Specialist Pa
-
Wilmington, DE
FULL_TIME
- ** Regular travel to satellite locations is required ** ESSENTIAL JOB DUTIES: Greets patients and visitors in a prompt, courteous and helpful manner. Obtains patient history and transcribes results in...
- 29 Days Ago
Benefits Specialist
- Genesis HealthCare
-
Kennett Square, PA
FULL_TIME
- POSITION SUMMARY: The Elder Care Line Benefits Specialist is responsible for coordinating all referrals/inquiries to the Genesis Network in a timely and seamless manner. Therefore, the Elder Care Line...
- 21 Days Ago
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0 Reimbursement Specialist - Healthcare jobs found in Wilmington, DE area
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- CareMetx
-
Springfield, PA
- [Administrative Assistant / Fully Remote] - Anywhere in U.S. / Competitive Pay - As a Data Entry Specialist you'll: Main...
- 4/23/2024 12:00:00 AM
Data Entry Specialist (Work From Home)>
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-
Lansdowne, PA
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- 4/23/2024 12:00:00 AM
Data Entry Specialist (Work From Home)>
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-
Middletown, DE
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- 4/23/2024 12:00:00 AM
Data Entry Specialist (Work From Home)>
- CareMetx
-
Upper Darby, PA
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- 4/23/2024 12:00:00 AM
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- CareMetx
-
Downingtown, PA
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- 4/23/2024 12:00:00 AM
Data Entry Specialist (Work From Home)>
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-
King Of Prussia, PA
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- 4/23/2024 12:00:00 AM
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Blackwood, NJ
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- 4/23/2024 12:00:00 AM
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Elkton, MD
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- 4/20/2024 12:00:00 AM
About Wilmington, Delaware
According to the United States Census Bureau, the city has a total area of 17.0 square miles (44 km2). Of that, 10.9 square miles (28 km2) is land and 6.2 square miles (16 km2) is water. The total area is 36.25% water.
The city sits at the confluence of the Christina River and the Delaware River, about 33 miles (53 km) southwest of Philadelphia. Wilmington Train Station, one of the southernmost stops on Philadelphia's SEPTA rail transportation system, is also served by Northeast Corridor Amtrak passenger trains. Wilmington is served by I-95 and I-495 within city limits. In addition, the twin-s...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Reimbursement Specialist - Healthcare jobs
$46,985 to $57,092
Wilmington, Delaware area prices
were up 1.0% from a year ago
were up 1.0% from a year ago
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