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Reimbursement Specialist - Surgical

Job ID 13975392 Date posted 11/01/2019

Job Summary

The Reimbursement Specialist for Surgical Specialties is responsible for claim and denial management, and unpaid claim follow-up. Must have coding knowledge for processing professional and facility claims to various types of insurance while maximizing reimbursement. Reimbursement Specialist is responsible for claim resolution through working claim edits and appealing denied claims in a timely manner. Must monitor status of outstanding Accounts Receivable balances. Able to relay detailed information regarding payer issues with suggestions for resolution to management. Deliver analysis for denial and reimbursement trends.

Essential Job Functions

  • Timely submission of office and surgical claims.
  • Maintain 3-day charge lag and keep track of any open/outstanding encounters.
  • Timely review of office and surgical charges to ensure optimal revenue capture.
  • Documentation review ensuring proper reporting of CPT, ICD-10-CM and HCPCS codes.
  • Managing all outstanding Accounts Receivable for assigned specialty(s).
  • Managing denials when present and filing appeals to payers for recovery.
  • Managing eligibility, authorization, medical necessity denials and documentation requests from payers within specified deadlines.
  • Review of outstanding insurance balances to identify and resolve issues resulting in a favorable outcome.
  • Maintain clear and cohesive claim notes related to all open and pending claims being worked.
  • Ability to navigate payer medical and reimbursement policies.
  • Stay current and compliant with coding, billing and HIPAA regulations.
  • Provide support to other areas in the Reimbursement Department, as needed.
  • Comply with departmental workflows and protocols.
  • Knowledge of professional and facility billing.
  • Ability to multi-task and work efficiently in fast paced environment.

Job Requirements


  • Minimum 3-5 years' experience of professional and facility billing as well as Accounts Receivable; preferably in a medium or large sized medical practice or hospital.
  • Knowledge of medical terminology and anatomy.
  • CPC/CPMA certification preferred.
  • Experience working in Practice Management Systems.
  • Proficient in Microsoft Office, Outlook and Excel, including pivot tables.
  • Ability to navigate and utilize payer specific portals including Navinet.
  • Strong working knowledge of billing, pre-certification procedures, CPT, ICD-10-CM, HCPCS, modifiers, coding and documentation guidelines.
  • Ability to understand insurance carrier protocols, policies and Explanation of Benefits and translate that information into an actionable workplan.
  • Maintain patient and company confidentiality (HIPAA).
  • Excellent verbal and written communication skills.
  • Attention to detail, accuracy, time management and organizational skills.
  • Ability to work effectively; independently and cohesively with other team members.




High School Diploma or equivalent (preferred)

CPC/CPMA certification (preferred)

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