Reimbursement Specialist

Position Summary:

Responsible for reimbursement evaluations for all HPI related facilities. Maintenance and reimbursement comparison of all payer fee schedule updates for both facilities and physicians.

Essential Functions: (3-5 core functions-75% of time spent)

• Must demonstrate excellent computer skills with an emphasis on Excel, Access, Allscripts, MedHost, Epic and Word.
• Thorough understanding of managed care and government reimbursement methodologies.
• Knowledge of the billing process for facilities and professional providers.
• Good interpersonal and communication skills.
• Ability to stay on task and complete assignments without direct supervision.
• Effectively working and cooperating with supervisors, co-workers, and clients.
• Following the directions of supervisors.
• Refraining from causing or contributing to disruption in the workplace.
• Regular and reliable attendance.
• Performs other duties as assigned.

Functional Accountabilities:

• Evaluates the proposed reimbursement rates for any new or amended facility payer contracts.
• Identifies, downloads and maintains all revised facility payer fee schedules as the fee schedule updates occur, uploads into billing software, and applies fee schedule revisions to internal spreadsheets in a timely manner as the internal spreadsheets are utilized by the facilities and CBO.
• Identifies, downloads and maintains all revised physician payer fee schedules, uploads into billing software and applies fee schedule revisions to internal spreadsheet in a timely manner as the internal spreadsheets are utilized by the physician office staff and CBO.
• Creates and maintains the facility payer contract summaries for the CBO.
• A thorough understanding of the facility reimbursement methodologies (Per Diems, MS-DRGs, Carve-Outs, Caps, Percentage of Billed Charges, Percentage of Medicare, etc.) is essential.
• Proficiency in the Epic Contract Management module by loading and maintaining Contract Rates.
• Interfaces with the CBO, facilities and Epic regarding any managed care contracted reimbursement issues and troubleshoots to identify and correct at the source.
• Communicates directly with the payers to seek resolution for any identified payer reimbursement issues.
• Work any reimbursement related inquiries from the facilities and perform requested reimbursement evaluations.
• Ability to be persistent in the pursuit of a prompt resolution regarding any reimbursement related issues.
• Assists with the negotiation of imaging payer single case agreements including reimbursement evaluation, and forwards to CFO for approval.
• Evaluates reimbursement for bundled payment single case agreements on a case by case basis which involves interfacing with the facility for any implant costs involved related to specific surgeon.
• Communicates with the facility accounting department to identify payments that should be distributed to the physician and anesthesiologist for their portion of a bundled payment upon receipt of the bundled payment to the facility.
• Maintains bundled payment agreement spreadsheet to ensure all information is entered, the facility claim or invoice has been received from the CBO, the hospital claim or invoice has been forwarded to the appropriate bundled payment entity, the bundled payment has been received by the facility, and the payment adjustments have occurred.
• Maintains the single case agreement spreadsheet to ensure all information is entered, and the facility single case payment has been received. If not, sends communication to the payer asking for payment resolution.
• Persistent follow up skills both externally and internally with payers, facilities, CBO and physician office staff are essential.
• Responsible for payer communication regarding any payer related issues: payer inquiries to facility, payer reimbursement issues, policy changes, plan identification, etc.
• Maintains the list of physicians and payer plans in Epic.
• Maintains the Department of Labor (DOL) list of users, resets passwords as needed and adds new users as requested by the facilities and the CBO.
• Reads managed care/healthcare related newsletters on a daily basis to keep apprised of any changes in the market and advise the supervisor of any upcoming changes, trends, reimbursement issues, etc.
• Maintains cross-training with other positions within the Contracting Department.
• Research fee schedule related issues and identify if a fee schedule has changed and should be revised in the Epic Contract Management module.

Accountability:

• Reports to: Director of Managed Care .
• Supervises: None

Qualifications: (Minimum education, training and experience, licensure, certification)

• College degree preferred.
• 3 years of experience in a professional or hospital claims. 6 months of experience working with CPT and ICD-10.
• Experience with MedHost preferred.
• Managed care experience preferred.
• Experience with Epic preferred.
  

Competitive benefits offered to full time employees, spouses and eligible dependents!

• Medical
  • Minimal out-of-pocket expenses for services provided by the company.
  • Standard PPO benefits for 2 nd tier providers/facilities.
  • Generous prescription plan available with enrollment on the medical plan.

• Dental
  • Two in-network options when choosing a dentist for maximum savings and lower out-of-pocket expenses.

• Vision
  • The largest national network of private-practice doctors making it easy to find the in-network doctor who is right for you.

• Section 125 Plan offered to include pre-tax premiums for Medical, Dental and Vision as well as flexible spending for unreimbursed out of pocket eligible medical expenses and dependent care.
• Company Paid Life Insurance policy for employee with option to purchase additional coverage for employee, spouse and/or dependents.
• Company Paid Long Term Disability which goes into effect after an absence due to medical disability for more than 120 days.
• Short Term Disability available for purchase to bridge the gap between being out and when long term disability kicks in if applicable and allows employee to avoid exhaustion of paid time off.
• Accident Insurance and Critical Illness coverage available for purchase on employee, spouse and/or dependents.
• 401(k) with a generous match.
• Generous paid time off accrual program.
• 7 paid holidays.