Summary:
The Reimbursement Specialist is responsible for assisting the Reimbursement Supervisor and fellow staff in following up with commercial and governmental payers to ensure timely resolution of billing issues and accurate claims reimbursement. This individual is also responsible for collaborating with other departments to drive payer collections, communicating process issues and improvements to the supervisor and training new staff.

Job Duties & Responsibilities:

Identifies and analyzes underpayments to determine the reasons for discrepancies and processes denials and appeals; examines claims to ensure payers are complying with contractual agreements.

• Reviews posted payments to ensure accuracy; analyzes explanation of benefits to ensure proper reimbursement.
• Communicates directly with payers to follow up on outstanding claims and resolve payment variances, responds to payer inquires and concerns, and works to develop and maintain positive relationships with payers.

Monitors and reviews denial reason codes and underpayments to identify root causes; works with payer contracting and other areas of the revenue cycle if necessary to resolve issues.

• Analyzes data to track collection efforts, identify trends, and provide team with updates and ideas for improvement.
• Monitors payer files for accuracy, ensures payer documentation is completed by follow up staff, and assists in updating files with pertinent information as necessary.

Assists other follow up staff in identifying high-risk accounts and prioritizing follow up efforts.

• Helps to work and resolve accounts from other staff members workloads to prevent backlogs and fills in as needed for absent staff.

Maintains superior understanding of claims management, third party payer guidelines, state and federal regulations, and all other functions of the job; educates and trains other follow-up staff as needed.

• Collaborates with other departments to identify best-practice collections strategies, align goals, and improve collections.
• Maintains compliance with HIPAA guidelines and ensures staff maintain discrepancy when handling patient information

Promote a team atmosphere by treating individuals with respect and honesty and by using direct communication and active listening skills.

• Be open to change and actively support change.
• Be open to others’ ideas and points of view.
• Evaluate employees objectively and provide employees with periodic feedback.

Promote department goals as well as the mission of the hospital.

• Communicate goals to fellow staff members.
• Maintain department policies and procedures.
• Include requirements and guidelines from external agencies (i.e., Joint Commission, State of Wisconsin).
• Maintain and/or communicate to appropriate party function backlog at a set time.
• Educate new staff regarding regulations or requirements of those functions that relate to their areas or departments, as directed.
• Demonstrate acceptance and training of student interns in the department, as directed.

Participate in hospital committees, performance improvement team meetings, and team projects, as directed.

• Demonstrate punctuality and preparedness.
• Demonstrate effective communication skills.
• Demonstrate good organizational skills.
• Contribute in a positive, solution-focused manner.

Conduct self in a professional manner.

• Demonstrate organizational skills that promote timely response to all inquiries and to task completion.
• Communicate with all individuals in a positive and professional manner.
• Attempt to resolve individual issues with peers in a positive, calm manner, with a focus on solution.
• Communicate concerns and provide solutions for same.
• Project a professional image by wearing appropriate, professional attire.
• Ability to influence departments within Rogers and provide technical guidance.

Additional Job Description:

Physical/Mental Demands:

• This role primarily involves sedentary work, requiring the employee to sit for extended periods. Occasional walking, standing, or reaching may be necessary to retrieve materials or operate office equipment. Lifting is moderate; must be capable of lifting a minimum of twenty (20) pounds. Reaching, handling, grasping and manual dexterity are necessary to operate various equipment.
• Verbal and hearing ability are required to interact with staff, consultants, patients and family members of patients. Numerical ability is required to maintain records and operate a computer.
• Tact is required to interact effectively with employees and professional staff. Logical thinking and discretion required to make decisions in initiating and implementing policies and procedures and standards.
• Must be able to read and communicate through written, verbal and auditory skills and abilities.
• Must be physically/mentally able to perform job duties as verified by a physical exam by a licensed physician, per post-employment physical.

Education/Training Requirements:

• High school diploma or equivalent required
• Associate or bachelor’s degree preferred
• Minimum of three years of relevant experience in mental health or medical insurance billing and/or collections required
• Minimum of three years working in Patient Financial Services encompassing all levels of care and UB04 and HCFA 1500 claims billing required
• Demonstrated knowledge of and experience with third-party payer guidelines, reimbursement, follow-up, and collections
• Demonstrated knowledge of claims review and analysis; ICD-10, CPT, and HCPCS coding; and medical terminology
• Effective communication, leadership, organizational, and problem-solving skills
• Ability to manage multiple tasks and projects simultaneously
• Ability to analyze data, identify improvement, and implement change
• Strong interpersonal and customer service skills
• Proficiency with Microsoft Word, Excel, Outlook, Teams, OneNote and Oracle Health Patient Accounting systems.
• Ability to work quickly and effectively in a fast-paced detail-oriented environment while adhering to deadlines.

With a career at Rogers, you can look forward to a Total Rewards package of benefits, including:

• Health, dental, and vision insurance coverage for you and your family 
• 401(k) retirement plan 
• Employee share program 
• Life/disability insurance 
• Flex spending accounts  
• Tuition reimbursement 
• Health and wellness program
• Employee assistance program (EAP)

Through UnitedHealthcare, UMR and HealthSCOPE Benefits creates and publishes the Machine-Readable Files on behalf of Rogers Behavioral Health. To link to the Machine-Readable Files, please visit Transparency in Coverage (uhc.com)