Reimbursement & Billing Specialist - NOT Remote

TITLE: Reimbursement & Billing Specialist, on site in Kenai Alaska

REPORTS TO: CFO

WORK WEEK: Hours not to exceed 40 per week

WAGE CLASSIFICATION: Non-exempt

OSHA RISK CLASSIFICATION: Low

SUMMARY POSITION STATEMENT

The Reimbursement & Billing Specialist secures accurate and timely payment for services by performing medical billing, claim submission and follow-up, payment posting, denial resolution, appeals, accounts-receivable management, patient account resolution, reconciliation, and reporting for medical, dental, optometry, and/or behavioral health services.

The position also verifies insurance coverage and benefits, coordinates referrals and prior authorizations, supports financial eligibility programs, and works with patients, providers, staff, and payers to reduce denials, accurately determine financial responsibility, and support access to care.

ESSENTIAL FUNCTIONS/ROLES & RESPONSIBILITIES OF THE POSITION

• Reimbursement and Claims Management
• Process assigned charges and claims independently; review documentation, diagnosis and procedure codes, modifiers, charges, and payer requirements; and submit accurate claims within timely-filing limits.
• Monitor claim status, resolve rejected, denied, unpaid, or underpaid claims by correcting information, obtaining documentation, and following up with commercial payers, Medicare, Medicaid, and other third-party payers.
• Research payer policies, medical-necessity requirements, contracts, fee schedules, and allowable amounts; prepare corrected claims, reconsiderations, and appeals and track them through resolution.
• Post patient payments, adjustments, and other account activity accurately in applicable systems.
• Review remittance advice and contracted allowable and resolve payment discrepancies, underpayments, overpayments, credit balances, and refunds.
• Reverify coverage and coordination of benefits as needed; correct payer order, reprocess or rebill claims, and transfer balances to the appropriate payer or patient.
• Generate patient statements, answer billing questions, collect payments, establish approved payment arrangements, and perform compliant collection follow-up on unpaid accounts.
• Process and balance credit-card transactions, deposits, and daily postings; investigate variances and complete weekly reconciliation and assigned month-end closing procedures.
• Maintain complete account notes, work queues, supporting records, and current desktop procedures; identify reimbursement trends and support denial prevention and workflow improvement.
• Prepare and provide Good Faith Estimates to patients before services are rendered.
• Eligibility, Benefits and Prior Authorization Responsibilities
• Verify and document insurance eligibility and benefits, including effective dates, plan status, network participation, covered services, exclusions, visit limits, deductibles, co-payments, coinsurance, and other patient-responsibility information.
• Confirm coordination of benefits and payer order and obtain corrected or updated insurance information before claim submission whenever possible.
• Determine referral, notification, precertification, and prior-authorization requirements; gathering supporting clinical information and submit and track requests.
• Follow pending requests, document authorization details, respond to requests for additional information, and assist with authorization denials, peer-to-peer reviews, reconsiderations, and appeals as assigned.
• Veterans affairs prior authorization for upcoming services for patients
• Communicate coverage, benefit, authorization, noncoverage risk, and estimated patient-responsibility information promptly to patients, providers, clinical staff, scheduling staff, and billing staff.
• Provide professional telephone and in-person assistance
• General Responsibilities
• Maintain consistent attendance and punctuality and respond promptly to assigned email, work queues, and follow-up tasks.
• Complete required training and follow confidentiality, HIPAA, infection-control, safety, and organizational requirements.
• Report operational or compliance concerns and perform other duties assigned by the CFO.

POSITION REQUIREMENTS

Education: High school graduate or equivalent. Medical billing, coding, reimbursement, AAPC, or AHIMA certification is preferred.License:No license is required. Relevant billing, coding, reimbursement, or patient-access certification is preferred but not required.Experience:Three to five years of healthcare billing, claims processing, reimbursement, payment posting, accounts receivable, eligibility, or prior-authorization experience preferred. FQHC experience is preferred.Systems:Experience with electronic health records, practice-management systems, payer portals, clearinghouses, and eligibility or authorization systems. eClinicalWorks, InSync, EyeCloud Pro, or similar experience is preferred.

Job Requirements:

• Working knowledge of healthcare billing, reimbursement, claims processing, collection rules, payer requirements, timely filing limits, contracts, and denial-resolution practices.
• Knowledge of ICD-10, CPT, and HCPCS coding and the relationship among documentation, medical necessity, authorization, claim adjudication, and reimbursement.
• Knowledge of insurance eligibility, benefits, coordination of benefits, referrals, and prior-authorization workflows.
• Computer proficiency with Microsoft Office, electronic health records, billing systems, payer portals, and standard office equipment; ability to type at least 45 words per minute with accurate 10-key skills.
• Strong attention to detail, analytical and organizational skills, time management, and the ability to prioritize and complete work independently.
• Ability to discuss coverage, authorizations, claims, account balances, and payments professionally and tactfully with patients, staff, providers, and payer representatives.
• Positive and collaborative work style, commitment to patient service, and ability to pass the State-required background check and pre-hire drug screen.

Contact: Patty Eissler, HR Director, peissler@pchsak.org or 907-260-5017

www.pchsak.org

PCHS is an equal opportunity employer and ADA compliant agency.