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)
POSITION SUMMARY/RESPONSIBILITIES
Identifies and enrolls indigent and under-insured patients into drug assistance reimbursement programs which provide drug replacement and reimbursement compensation. Monitors continued eligibility status and documents drug shipments received in computerized tracking system. Serves as a resource in facilitating resolution of insurance denial referrals. Communicates effectively with pharmacy, hospital administration, medical staff, patients and personnel in the patient assistance programs using verbal and written interpersonal communication skills. Requires ability to work independently and coordinate assigned projects efficiently. Effectively utilizes problem solving ability, significant interpersonal contact and concentration abilities, analytical skills and in depth knowledge of computer software. Coordinates all information regarding patients enrolled in assistance programs for drug therapies using various computer software programs. Creates, expand and maintains computerized databases to support patient enrollment in assistance programs and tracks case specific assistance provided in response to reimbursement denials. Conducts patient interviews and conveys reimbursement denial potential to patient and medical staff. Reviews all outpatient 3rd party rejections and assists the patient in resolving the problem. Coordinates 3rd party billing, problems with eligibility, rejections, etc with the Outpatient Pharmacy Supervisor and the Pharmacy Billing Section.
EDUCATION/EXPERIENCE
Texas State Board of Pharmacy registration required. National Certification as a Certified Pharmacy Technician (CPhT) is recommended. Three years experience in a medical or pharmacology related field to include project coordination; database/spreadsheet development and management; and/or application programming; processing and overseeing medical insurance billing and reimbursement cost capture. Must have demonstrated independent judgment