Reimbursement Specialist

Responsible for review of all patients requiring chemotherapy and adjunctive infusions, including confirmation of patient insurance benefits, reimbursement, and determination of any patient responsibility. Communicates findings with clinical team and patient. Reviews open accounts to evaluate claim status and intervenes appropriately to assure proper payment. Works with patients to determine availability of oncology specific assistance programs. 

* THIS IS NOT A REMOTE POSITION*

Responsibilities:

• Demonstrates effective problem-solving, an ability to communicate verbally and in writing, and a willingness to adapt to changing environment. Promotes and maintains positive working relationships within the department and with other areas throughout PinnacleHealth, the community and outside agencies. Demonstrates professionalism with fellow employees, providers, and patients in person, on the telephone, and in writing. Demonstrates by his/her own behavior a strong sense of commitment to patient care. Demonstrates respect for individual dignity and diversity.
• Prepares specific financial reports as assigned.
• Insurance Account Management:
  • Researches rejections and investigates problems, resubmitting and/or appealing claims where appropriate.
  • Periodically monitors progress of appealed claims and communicates provider representative until claim is paid appropriately. Provides additional information as needed to facilitate payment.
  • Reviews any invoices over 60-90 days for possible problems and resubmission.
  • Reviews claim denial trends and communicates with the insurance companies as appropriate to resolve issues that may prevent payment for services.
  • Communicates with individual departments on any issues that are a result of their front office functions.
  • Possesses knowledge of insurance policy, guidelines, and referral/authorization processes.
  • Maintains up to date information on insurance policies and procedures, billing information, and contacts.
  • Abstracts data from medical records to provide accurate and timely information for billing, medical necessity, and reimbursement.
  • Works with Director of Payer Relations to proactively identify services not outlined effectively in payor contract
• Financial Issues:
  • Assigns codes to diagnosis and procedures according to the ICD-9 CM and CPT guidelines.
  • Enters or reviews outpatient charges using appropriate diagnosis codes and modifiers in the Invision system
  • Verifies that all charges have supporting documentation.
  • Reviews charges for correct coding, completeness and accuracy of demographic and insurance data.
  • Bills the charges from SSI as applicable.
  • Audits payments from insurances for compliance with contractual amounts.
  • Maintains knowledge of coding standards and guidelines
  • Performs liaison functions between the Department Director/Supervisor and Physicians for coding and reimbursement accuracy.
  • Works closely with clinical staff, physicians, other department stakeholders, patient accounting and scheduling areas.
  • Assists Supervisor/Director with ongoing education to physicians and others as it relates to identified issues with coding and billing.
  • Compares treatment provided in hospital versus physician practice to evaluate reimbursement and patient responsibility for planning.
• Patient Account Management:
  • Must have a solid working knowledge of insurance plans and benefit structures on both the hospital and practice side, in order to obtain detailed benefit information and maximize plan benefits.
  • Obtains payor specific pre-determination and/or prior authorization procedures and documentation requirements. If applicable facilitates the prior authorization process for patients and healthcare providers.
  • Determine medical necessity based on current policies and stays updated on clinical bulletins with individual insurance carriers.
  • Collect coinsurance and deductibles from patients as appropriate.
  • Reviews accounts without insurance, verifies MA application process, charity care application and/or drug replacement program availability.
  • Reviews accounts with potential bad debt liabilities and provides appropriate follow up.
  • Communicates with patient regarding financial responsibility to establish a course of action either from the standpoint of applying for medical assistance, setting up a payment plan, or educating them on the compliance and expectations related to other insurance benefits.
  • Updates patient account information as required.
  • Familiar with the specific health care benefits of each of the Medical Assistance insurers. Works with the patient until the proper paperwork is on file.
  • Receives and resolves patient billing inquiries.
  • Evaluates eligibility for patient to receive free drug based on diagnosis, insurance, and financial information. Obtain proper consents and documentation.
  • Identify patients eligible for co-pay assistance based on diagnosis and financial information. Facilitate application process with patient.
  • Identify insufficient reimbursement or significant patient responsibility for oncology specific drugs. Communicate with patients Specialty Pharmacy to order and obtain the drug as appropriate.