Account Reimbursement Specialist III

Job Summary: The Account Reimbursement Specialist III is an advanced-level revenue cycle professional and subject matter expert responsible for complex insurance account reimbursement, denial resolution, claim follow-up, and payer-related research. This role demonstrates a high level of expertise in physician practice billing, payer reimbursement methodologies, claim requirements, appeals, payment variance analysis, and regulatory guidelines. The Account Reimbursement Specialist III is responsible for resolving complex, high-dollar, aged, and escalated accounts that require advanced research and payer intervention. The position serves as a resource and subject matter expert for Account Reimbursement Specialists and other RCM team members, providing guidance on complex reimbursement issues, payer policies, denial resolution strategies, and claim correction requirements. This role also identifies systemic reimbursement issues and denial trends, performs root-cause analysis, and partners with RCM leadership and operational teams to implement solutions that improve reimbursement, reduce preventable denials, and strengthen revenue cycle performance. The Account Reimbursement Specialist III is a key contributor to maximizing net collections and ensuring accurate and timely reimbursement. Primary Job Responsibilities: Performs all responsibilities of the Account Reimbursement Specialist I and II positionsServe as a subject matter expert (SME) for complex account reimbursement, payer requirements, denial resolution, claim follow-up, appeals, and reimbursement issuesManages and resolves complex, high-dollar, aged, and escalated insurance accounts requiring advanced investigation and payer interventionPerforms advanced research of payer policies, contracts, medical necessity requirements, reimbursement guidelines, claim processing rules, and payer-specific requirements to determine appropriate resolution strategiesAnalyzes complex Explanation of Benefits (EOBs), remittance advice, payment discrepancies, contractual adjustments, bundling issues, underpayments, overpayments, and non-payment scenarios to determine appropriate account resolutionDevelops and submits complex reconsiderations, appeals, medical necessity appeals, corrected claims, and other payer disputes when appropriate to secure maximum reimbursementConducts detailed claim research across payer portals, payer correspondence, medical records, claim history, authorization information, coding, charge capture, and other available documentationResolves difficult denials, including but not limited to medical necessity, bundling, authorization, eligibility, timely filing, coding, modifier, coordination of benefits, non-covered services, contractual, and payer processing issuesIdentifies accounts requiring escalation and appropriately coordinates with RCM Leadership, coding, to achieve resolutionTracks and follows complex accounts through multiple levels of payer review and escalation, maintaining detailed documentation of actions taken, payer responses, and required next stepsServes as an escalation resource for Specialist I and II staff by providing guidance on complex accounts, payer policies, denial resolution, and appropriate follow-up strategiesProvides peer-to-peer coaching and knowledge sharing to RCM team members on complex reimbursement issues, payer changes, denial trends, and best practicesIdentifies opportunities for recovery of previously denied, underpaid, or incorrectly processed claims and develop strategies to pursue additional reimbursementAssists with developing and maintaining payer-specific workflows, denial resolution guidelines, reference materials, and other RCM resourcesSupports training and onboarding of new and existing RCM team members by providing subject matter expertise and guidance on complex reimbursement functionsMay perform quality reviews of account reimbursement activities to identify training opportunities, documentation gaps, or process inconsistenciesPerforms patient and insurance payer outreach to research and resolve complex payment-related inquiries and Athena patient accountsMaintains accurate and comprehensive account documentation in accordance with departmental standardsMeets established productivity, quality, follow-up, and cash collection expectationsMaintains current knowledge of payer policies, reimbursement methodologies, medical billing requirements, and applicable regulatory changesPerform other duties and special projects assigned Requirements: Minimum of five (5) years of progressive and complex healthcare revenue cycle, medical billing, or insurance reimbursement experience in a physician office, ambulatory surgery center, or centralized medical business officeStrong knowledge of physician practice billing, claim submission requirements, payer processing rules, and accounts receivable follow-upStrong understanding of medical terminology, ICD-10, CPT, HCPCS, modifiers, and common coding-related reimbursement issuesStrong analytical and problem-solving skills with the ability to identify root causes and develop appropriate resolution strategiesAbility to research payer policies and apply guidelines to individual account situationsDemonstrated ability to work independently and exercise sound judgment on complex accountsAbility to serve as a resource and mentor to less experienced team members without direct supervisory responsibilityExcellent verbal and written communication skillsStrong customer service and professional communication skillsExcellent computer skills, including Microsoft Word and ExcelExperience with Athenahealth/AthenaOne preferredAbility to manage multiple priorities, organize daily workload, and meet established productivity, quality, and accuracy standards Education and Certifications High school diploma or equivalent requiredAssociate degree in Business, Healthcare Administration, Medical Billing, Revenue Cycle Management, or related field highly preferred. Physical Requirements Work consistently requires walking, standing, sitting, lifting, reaching, stooping, bending, pushing, and pullingMust be able to lift and support weight of 35 pounds. Ability to concentrate on detailsUse of computer for long periods of time