Sr Reimbursement Spec

About the role

This pharmacy position is responsible for Medicare as a payer. The role requires great attention to detail and analytical thinking due to the complexity of Medicare/Medicaid regulations. Responsibilities include day-to-day functions of assigned accounts, maintaining and updating billing activity, ensuring accurate and timely billing, collections, and appeal of home infusion claims. Tasks also involve performing collection tasks to obtain payments, generating and monitoring aging reports, analyzing accounts for documentation, authorization, LCD, and necessary information, and providing superior customer service.

Responsibilities

• Day-to-day functions of assigned accounts
• Maintain and update billing activity
• Ensure accurate and timely billing, collections, and appeal of home infusion claims
• Perform collection tasks to obtain payments
• Generate and monitor aging reports
• Analyze accounts for documentation, authorization, LCD, and all necessary information to determine the next step in the process
• Provide superior customer service in person and on the phone to internal/external customers
• Process third party and patient remittances, including posting payments, credits, and adjustments
• Timely and accurate application of payments on third party and patient accounts
• Complete required Medicare training
• Understand Medicare regulations and guidelines applicable to home infusion services
• Verify Medicare Criteria using Medicare Local Coverage Determination (LCD) for covered therapies
• Understand ABN and CMN/DIF processes
• Utilize applicable kit codes and modifiers when billing Medicare claims
• Understand Medicare appeal process and utilize correct appeal forms
• Provide superior customer service, in person and on the phone, to all insurance companies, Fairview entities, and patients
• Communicate effectively, both written and verbal
• Communicate appropriate information to others according to established procedures to support day-to-day operations
• Process home infusion claims accurately and timely
• Review accounts for all needed information and communicate to correct departments to add information needed to ensure proper billing
• Screen claims on-line or on paper for accuracy
• Obtain appropriate information to process claims
• Communicate and request necessary information from payers, patients, Fairview Department
• Interpret and demonstrate accurate application of third-party payer and government payer contracts
• Understand regulatory, HMO, PPO, Federal, State, and other third-party payer requirements needed to prepare and or process claims
• Generate and monitor aging reports on third party payers
• Communicate denials and Eligibility of Benefits (EOB’s) to insurance company and patients
• Review aging reports that have reached certain aged categories (30,60,90 days, etc.)
• Maintain reports to 60 days
• Generate home infusion claims for resubmission for third party payer’s outstanding balances
• Perform collection tasks to obtain payments from third party payers, government, and private accounts
• Negotiate payment plan arrangements with delinquent patient accounts
• Prepare and request any credit or debit adjustments
• Research and refund patient or insurance company for overpayments
• Request adjustments on incorrectly processed claims
• Provide clear and precise documentation
• Accurate and timely notation in computer system
• Review and process correspondence
• Patient orders
• Rejections/denials
• Medical record requests
• Itemized bills
• Clarification of detail on bill
• Maintain and update patient accounts
• Screens claims online and or on paper for accuracy
• Assist clients regarding billing questions and ensure appropriate resolution of problem(s)
• Document and maintain files
• Process third party payers and patient remittances
• Interpret and demonstrate accurate application of third-party payer EOB's
• Understand Federal, State, and other third-party payer requirements needed to prepare and process payments
• Document and maintain files to support reconciliation of amount posted to amount deposited
• Post receipts within two working days after deposit
• Prepare, scan and file documents in appropriate area

Requirements

• High School Diploma/GED
• 3-5 years medical billing or collection experience, Medicare, Medicaid, Third Party experience
• Maintain current knowledge of government and private payer requirements and regulations
• Attend and or complete necessary ongoing training
• Proficient in the English language
• Proficient math skills
• Proficiency with PC software and A/R systems essential including basic typing skills
• Ability to maintain an environment of honest and confidential communications
• Ability to communicate as needed, both written and verbal information in a clear, concise, accurate and considerate manner
• Ability to deal professionally, courteously, and efficiently and to remain calm under stress
• Proven ability to problem-solve effectively

Qualifications

• Vocational Training
• Technical Training
• Associate Degree or Certified Medical Billing
• 5+ years of Medicare billing and collections experience for home infusion
• Pharmacy knowledge helpful
• Certified Pharmacy Technician

Skills

• Attention to Detail
• Analytical Thinking
• Customer Service
• Medicare Regulations Knowledge
• Medicare Claims Processing
• Medicare Appeals
• Third Party Insurance Knowledge
• Medication Management
• Communication Skills
• Math Skills
• Computer Proficiency
• Problem Solving

Benefits

Fairview offers a generous benefit package including medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! For additional information, please visit: here.

Pay

Compensation within the posted range may be determined by various factors, including skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization prioritizes pay equity and considers internal team equity when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign-on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.

Schedule

The schedule for this position is typically full-time.