Reimbursement Specialist Resume Samples

Description :

1. Conduct benefit investigations, verify insurance benefits for patient and physicians' office and submit and obtain prior authorization as required by payer.
2. Obtain recertification for cases requiring extended treatment/coverage beyond the expiration of original approval Accurately enter and maintain data as required in client database and patient files and utilize the client database to monitor outstanding items on each client case file.
3. Ensure files are complete so the team can determine the current status.
4. Participate in conference calls with Client Sales Representatives, client management and physicians' offices regarding the status of cases, drug orders and status of alternative funding.
5. Provide coordination of order for a product, a shipment of product, and therapy initiation with pharmacy and patient.
6. Participate in Call Center Activities, triage and respond to incoming calls from patients, insurance companies, physicians, Sales Reps, pharmacies, and home care agencies.
7. Identify and report events as required by the REMS requirements for specified medication.
   

Experience

7-10 Years

Level

Management

Education

Criminal Justice

Description :

1. Perform initial assessment to determine patient's need for home care services and provide information to clinical team.
2. Identify payer sources, verify benefits, negotiate rates and obtain authorization for services.
3. Ensure accounts are paid in accordance with terms of contact and notify management team of any potential problems with payer source.
4. Document and maintain patient files to comply with company policy, legal requirements and regulatory mandates.
5. Payroll and Data Entry Clerk Maintain admission and billing data for 375- 400 patients and payroll information for 18 clinical professionals in the local office using CaseMatch software.
6. Verify completeness and accuracy of information maintained in database for consistency with company policies, legal requirements, and Federal healthcare regulations, including HIPAA.
7. Compile and distribute compliance documentation as requested by management and operations staff.
8. Collect data from internal and external sources to respond to requests for information, obtaining appropriate approval and maintaining log of requests.

Experience

10+ Years

Level

Senior

Education

Bachelor Of Science

Description :

1. Accurately and timely post all cash, checks, credit cards, and electronically transferred funds to customer's accounts.
2. Researches and corrects reconciling items from various bank accounts and coordinates with various internal and external personnel to correct any errors discovered in research.
3. Creates, enters, and posts adjusting entries to clear outstanding reconciling items.
4. Research incoming payments for adequate information to ensure appropriate allocation and account reconciliation.
5. Research, audit, approve, and process patient refunds, ensuring that overpayments are identified within timely manner and processed according to policy.
6. Led and managed successful conversion from paper batch posting to CashPro imaging.
7. Played vital role in conversion to GE Groupcast practice management system, ensuring timely and accurate acceptance of electronic remittance advice from health plans.
8. Responsible for obtaining banking reports from on-line banking web services, reconciling monthly statements, and distributing reports as necessary.

Experience

2-5 Years

Level

Junior

Education

Bachelor Of Science

Description :

1. Utilizing and understand provider guidance and eligibility processes, in order to make necessary updates to various internal systems required for enrollment into Express Scripts Prescription Drug Plan.
2. Serving as first point of contact for internal clients and members during the enrollment process.
3. Making outbound and receiving inbound calls from physician offices, patients, and potential clients including correspondence regarding member eligibility.
4. Make independent judgements in order to respondtoncomplex or critical issues.
5. Work collaboratively with eligibility system analysts, eligibility associates, eligibility managers, and account managers to provide seamless support to our clients.
6. Identify and escalate repetitive questions and/or problems so that corrective action can be pursued and expedited.
7. Maintain accurate and complete documentation of all contacts to continually improve the process and reduce potential legal concerns or payouts.
8. Complete other projects and additional duties as assigned.

Experience

2-5 Years

Level

Junior

Education

Healthcare Management

Description :

1. Support practice management by handling administrative responsibilities required to keep accurate records of patient information.
2. Gather and verify insurance details for specific diagnosis and procedures being rendered to patients; provide information to physician.
3. Utilize high level of knowledge/expertise in billing and reimbursement to accurately log medical records.
4. Maintain positive relationships, collaborate with departments, payers, and business partners to protect the interests of the company and its customers.
5. Reduce/eliminate rejected claims by reviewing medical documents to ensure patient insurance covers treatments being rendered.
6. Verify patient insurance benefits and eligibility by making outbound calls to various insurance companies.
7. Address compliance-related matters proactively by verifying CPT, ICD9 and diagnosis codes are accurate and current, per regulation standards.
8. Review appropriateness of CPT, ICD9 coding prior to submitting for billing of claims.

Experience

5-7 Years

Level

Executive

Education

CPT In Verification

Description :

1. Accounts receivable management for a Joint Commission accredited durable medical equipment company.
2. Currently responsible for all aspects, including insurance and patient billing and collections, processing of payments, payment disputes, reconciliations and adjustments, management of hardship program, financial reporting.
3. Responsible for review of claims prior to billing to ensure accuracy and completeness and that all documentation requirements have been met.
4. Assist in collection of accurate documentation when necessary.
5. Medicare specialist responsible for billing of claims and filing of appeals through ALJ level with an over 80% favorable decision rate.
6. Assist in ensuring that all Medicare Supplier Standards requirements are met.
7. Maintain insurance contracts and fee schedules.
8. Experience in all aspects of business including the entire order entry process, intake, qualifying, document collection, patient services, shipping, outside sales support, and accounts payable.

Experience

10+ Years

Level

Senior

Education

Business Administration

Description :

1. Collects and reviews all patient insurance benefit information, to the degree authorized by the SOP of the program.
2. Provides assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications.
3. Completes and submits all necessary insurance forms and electronic claims to process the claims in a timely manner as required by all third party payors.
4. Researches and resolves any electronic claim denials.
5. Researches and resolves any claim denials or underpayment of claims.
6. Effectively utilizes various means for collections, including but not limited to phone, fax, mail, and online methods.
7. Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
8. Maintains frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers.

Experience

5-7 Years

Level

Executive

Education

Phlebotomy

Description :

1. Identified and explored additional revenue opportunities for hospital-based physician earnings.
2. Analyzed financial transactions and provided variance analysis identifying trends, issues, and solutions affecting revenue.
3. Responsible for maximizing cash collections through efficient process flows, revenue identification and timely collection of receivables.
4. Identified and addressed favorable and unfavorable insurance carrier reimbursement trends used for forecasting.
5. Tracked and analyzed key financial and operational business metrics for optimal bottom-line revenue results.
6. Created and maintained databases and financial spreadsheets for senior management and physician review.
7. Followed-up on outstanding account receivables reviewed medical claims for accuracy, proposed account settlements and managed aging reports, resulting in additional $1.9 million recoveries.

Experience

2-5 Years

Level

Executive

Education

Certificate In Real Estate

Description :

1. Researched documentation in SalesForce to determine eligibility for the Bayer Pharmaceutical Diabetes patient assistance program.
2. Took inbound calls from healthcare professionals, patients, and sales representatives in regards to insurance inquiries.
3. Placed accurate and timely documentation of payer, billing information and patient status within the operations systems.
4. Acted as a liaison between the provider and sales representatives to resolve any prior authorizations inquiries or appeals of denials as part of a key account initiative program.
5. Conducted research to determine payer landscape in regards to determining coverage of benefits.
6. Maintained databases to reflect changes or updates to payer's policies.
7. Assisted in the preparation of/or prepared reports as requested by management.
8. Aided in the development of reimbursement tools, presentation materials, and program SOPs as requested by the program manager.

Experience

7-10 Years

Level

Management

Education

Bachelor Of Arts

Description :

1. Supporting a series of branch offices with accounting functions, such as invoicing corporate clients for services rendered.
2. Reviewing unpaid accounts to determine status and taking appropriate action to ensure payment.
3. Contacting corporate clients regarding reimbursement for unpaid accounts over thirty (30) days or more, by researching and following up on denials and requests for additional information.
4. Establish a relationship with account manager's and the facility's accounts payable department to ensure productive billing and collections.
5. Review various contracts and policies in order to execute accurate and efficient billing cycles.
6. Review payments for cash applications to various account branches within assigned region.
7. Research over and underpayments for individual invoices through programs such as Great Plains, Clearview, and Payment Coding Sites.
8. Manage accounts over $1 million in revenue each week.

Experience

2-5 Years

Level

Executive

Education

Masters Of Arts

Description :

1. Provided patient information for use by collection agency, physicians, and Account Manager.
2. Effectively communicated with patients, physicians' offices, hospital personnel and all IPMS staff in relation to billing, insurance and general information, to build and maintain positive business relationships.
3. Accurately recorded daily ca-sand credit card totals, distributed vouchers and posted EOBs manually and electronically.
4. Handled monthly payment reconciliation and collection agency turnover process for HPA.
5. Review insurance claims in the billing department and ensure that clients or customers receive accurate reimbursements for their claims.
6. Working in this position requires a strong attention to detail and a high level of familiarity with clerical and office processes.
7. Responsible for insuring timely and full allowable amount of payment according to contracts of each insurance company.

Experience

2-5 Years

Level

Junior

Education

General Studies

Description :

1. Took calls from health care professionals, patients, and sales representatives.
2. Provided assistance with medical and pharmaceutical reimbursement inquiry requests.
3. Provided billing and coding information related to specific product(s)/Hotline (CPT & ICD-9).
4. Verified patient health insurance benefits, and conducts general payer research.
5. Worked with insurance payers and health care professionals to resolve prior authorization issues and/or appeals and grievances of denials.
6. Assisted in the development of reimbursement tools, presentation materials, and program SOPs as requested by the program manager.
7. Assisted with reports using MS Word, PowerPoint and MS Excel as requested by the Program Manager.
8. Cultivated and managed relationships with key contacts at managed care organizations (Medical Directors, Directors of Contracting, etc.), CMS and medical professional societies.

Experience

7-10 Years

Level

Management

Education

Medical Billing & Coding