Specialty Medication Reimbursement Specialist

About the Role

Audits infusion and specialty medication claims to determine payment status and reasons for denials, then addresses root causes. Collaborates with payers, manufacturer programs, and internal billing teams to recover revenue and prevent recurring denials.

Responsibilities

• Monitor unbilled and unpaid infusion and specialty medication encounters to ensure timely claim submission.
• Audit paid claims against expected reimbursement using payer fee schedules and drug allowables (ASP, WAC, contracted rates).
• Investigate denials and underpayments, identifying causes such as authorization issues, benefits or site-of-care restrictions, coding or NDC/unit errors, documentation gaps, or unreimbursed copay assistance.
• Contact payers to verify coverage, fee schedules, and buy-and-bill vs. specialty pharmacy requirements for specific medications.
• Reconcile copay card and foundation assistance payments, and follow up on outstanding manufacturer reimbursements.
• Coordinate corrections and rebills with billing and intake teams, incorporating findings to prevent recurring denials.
• Report payer and drug-level profitability and denial trends to the Ancillary Services Manager.

Requirements

• 3+ years of experience in medical billing, reimbursement, or revenue cycle, with direct experience in infusion or specialty drug claims.
• Working knowledge of J-codes, NDC and unit billing, buy and bill, specialty pharmacy, and medical vs. pharmacy benefits.
• Ability to interpret payer policies, fee schedules, and EOBs, and explain denials in plain terms.
• Experience with copay assistance and manufacturer reimbursement reconciliation.
• Proficiency in Excel and payer portals; Power BI or reporting experience is a plus.
• Coding certification (CPC or similar) is a plus.

Benefits

• 401(k) matching
• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off