Sr. Reimbursement Specialist

at  Mimedx Group Inc

POSITION SUMMARY:

Determine eligibility and benefits, answer billing questions, and obtain authorizations, and predeterminations. Process insurance verification requests and secure prior authorization approvals for eligibility and benefit coverage. Research and answer questions as it relates to medical verifications of insurance policies, coding, billing, and claims. Conduct effective communications with the physician’s office, Health Plan, and the Company’s sales team. Assist in new hire onboarding training and help junior team members as needed, with a focus on accuracy and efficiency in processes and results. Adhere to all applicable policies, procedures, processes and systems in order to obtain accurate coverage information and optimize the maximum reimbursement levels.
We are excited to add a Sr. Reimbursement Specialist to our team! The position will pay between $57-70k base based on previous relevant experience, educational credentials, and location.

EDUCATION/EXPERIENCE:

• BS/BA in related discipline
• 2-5 years of experience in related field with 1-3 years of progressive responsible positions, or verifiable ability

OR

• MS/MA and 1-3 years of experience in related field. Certification is required in some areas
• 3-5 years of experience in insurance verification, billing/claims processing, data processing
• Thorough knowledge of medical coding including ICD10, CPT and HCPCS codes
• Thorough understanding of Medicare, Medicaid, and Commercial and health plans
• Thorough understanding of medical management, health insurance concepts, information systems
• Excellent understanding of HIPAA rules

SKILLS/COMPETENCIES:

• Excellent oral, written, and interpersonal communication skills
• Ability to interact with all levels of management, both internal and external, third party payers, and customers; with a focus on customer service
• Proficient in Microsoft Office (Excel, Word, etc.)
• Organized, flexible, and able to multi-task while maintaining a high level of efficiency and attention to detail
• Excellent analytical, problem solving, and trouble shooting skills
• Ability to make quick, sound decisions based on policy, past practices, and experience

EDUCATION

Required

• Bachelors or better

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Receive and process assigned clinical authorizations and insurance verification requests (IVR’s) from data intake team
• Review IVR and correct data entry errors and omissions (e.g. incorrect Health Plan, missing information, etc.)
• Determine if payer already in database; if not, research payer on website to obtain demographic information and add new payer information and their processes to database
• Obtain benefit coverage levels and prior authorization requirements from Health Plan, submit required paperwork, and follow-up on coverage requests and prior authorizations
• Enter coverage levels and/or prior authorization requirements for assigned accounts in database
• Research and review electronically stored health policy notes and historical reimbursements, coverage information provided by Health Plan, and procedural information (e.g. diagnosis, product, place of service, etc.) from provider to aid in making accurate coverage determinations
• Analyze and interpret collected data, obtain additional information as needed, make coverage determination, and notify provider of decision
• Collaborate with sales and field reimbursement teams to get complete and correct information to process IVR/s
• Research and/or respond to escalated, moderately complex questions from junior level members, as well as from physicians, hospitals, outpatient facilities/ambulatory care centers, etc. regarding billing, coding procedures, and processes
• Review and complete daily pending case reports to ensure prompt processing and closure of IVR’s and authorization requests
• Identify and escalate issues as they may arise throughout the process; report IVR quality issues in an effort to minimize errors in processing and coverage determinations
• Report changes/issues in coverage/reimbursement trends to management
• Identify and recommend system and/or process changes to improve efficiencies
• Follow HIPAA policies and procedures to ensure compliance
• Assist and participate in project workgroup(s) with various departments regarding needed improvements to database (Alfresco)
• Assist with new hire onboarding training; provide ongoing assistance to junior level team members
• Identify potential team member training needs/issues; conduct regular team training meetings
• Act as back-up to supervisor when they are unavailable or out of the office