Reimbursement Specialist

Pediatric Associates was founded in Hollywood, FL in 1955. The same clinician-led, evidence-based, medical home passion is a unifying driver for those who join Pediatric Associates Family of Companies.  The Pediatric Associates Family of Companies is a growing team of Pediatricians and Pediatric Care Teammates who are excited to be part of the first nationwide Pediatric Primary Care Medical Home. We further our uniqueness by ensuring the clinician voice is leading our medical home innovations.

PRIMARY FUNCTION:  

Reimbursement Specialist is responsible for analyzing the billing process to determine appropriateness in payment (reimbursement). This position manages all components of claims processing including: 1) coordination of disputed, rejected, and delayed claims, and 2) to problem solve and review returned, disputed or rejected claims from Government and other third party Payers. Additionally, this position is responsible for communicating with billers regarding coding processes to prevent future denials. 

ESSENTIAL FUNCTIONS OF THE JOB: (This list may not include all of the duties that may be assigned.) 

1. Processes correspondence related to assigned contracted and/or non-contracted insurance carriers including self-pay accounts. 

2. Researches denied and improperly processed claims by contacting assigned carriers to ensure proper processing of said claims. Call and check claim status, work A/R and insurance carrier reports, and insurance denials. Verifies insurance eligibility / PCP / patient benefits to reconcile denied claims. 

3. Identifies and corrects any claim processing errors due to data entry, verification, coding and/or posting. Add or update insurance carriers into practice management system. Review the Financial Class and the Insurance Group and verify that they are in the correct financial reporting groups. 

4. Resubmits improperly paid/denied claims to the carrier for proper payment in a timely manner. 

5. Monitor payer payment policies (bundling process) for each carrier to ensure guidelines are followed. 

6. Responsible for validating appeal opportunities, creating appeal letters, generating and submitting individual and/or batch appeals in a timely manner, tracking appeals and recoveries. Follow up on outstanding appeals, and work closely with the appropriate teams to validate contracts. 

7. Communicate and escalate denial trends, short payments, or payer policies to Management. 

8. Other various duties as assigned, including cross training in other functional areas. 

*Non patient-facing 

PERFORMANCE REQUIREMENTS: 

Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI in accordance with organizational policy, Federal, State, and local regulations. 

TYPICAL WORKING CONDITIONS:  

Indoor Work 

Operating Computer 

Reach Outward 

Manual Dexterity 

Lift/Carry 20 lbs. or less 

Push/Pull 12 lbs. or less 

Sitting 

Other Physical Requirements 

Vision 

Sense of Sound 

Sense of Touch 

EDUCATION: High school diploma/GED or equivalent. 

LICENSURE/CERTIFICATION: None 

EXPERIENCE: Minimum of 1 year of insurance/collection experience in a medical environment preferred. 

 
KNOWLEDGE, SKILLS & ABILITIES:  

• Knowledge of billing and collection policies and procedures, all types of insurance (HMO, PPO, POS, Medicaid etc.)  

• Skill in defining problems, diagnostics of common coding errors, and impact on claims processing, collection of data, interpreting billing information.  

• Must possess strong interpersonal skills; must be able to communicate effectively with co-workers, the Business Office Manager and must be able to work effectively as a team member within the Business Office.  

• Ability to multi-task in a face paced environment while meeting established production and quality goals/metrics.  

• Strong organizational skills, with ability to effectively prioritize work and daily basis and follow up on open items in a timely manner