Reimbursement Specialist - Healthcare Appeals, A/R & Payor Collections

The Reimbursement Specialist II ensures that healthcare providers and organizations are appropriately reimbursed for their services. They are responsible for verifying insurance coverage, submitting reimbursement claims, and communicating with insurance companies, patients, and healthcare providers. In addition, they must stay up to date with changes in insurance policies and regulations that may affect reimbursement procedures.

Core Duties/Responsibilities :

Ensure timely collection of outstanding Accounts Receivable and resolution of billing/claims issues.

Research, evaluate, and interpret complex information relative to appeals, payor specific billing policies, and guidelines related to insurance.

Manage assigned accounts to ensure timely and appropriate actions are taken to ensure positive cash flow.

Required to stay up to date with changes in insurance policies and regulations that may affect reimbursement procedures which include commercial, Medicare, Medicaid and Workers Comp payers.

Identify any payments not made in accordance with contracted rates and fee schedules and properly escalate the incorrect payment to the payer.

Cross train to provide department coverage.

Varying clerical and light accounting work.

Additional duties may include data entry, record keeping, participating in projects, and other administrative support as needed.

Skills / Requirements

Extensive experience with appeals, payor specific billing policies, and guidelines related to insurance and collection follow-up.

In-depth understanding of healthcare billing and coding processes.

Ability to understand and navigate complicated insurance policies and regulations.

Excellent written and verbal communication skills throughout a variety of stakeholders, including insurers, patients, and healthcare providers.

Strong organizational skills, attention to detail, and effective task management while responding productively to changing priorities.

Remains calm and objective in emotional or stressful situations.

Learns quickly and applies innovative methods, tools, and technology to the role.

High level of self-accountability for compliance with policies, procedures, and work requirements.

Seeks advice when unsure about choosing a course of action.

Makes solid routine decisions with coaching from others.

Learns about the key drivers of the organization’s business and uses those learns in the day-to-day work.

Maintains tenacity and work focus despite obstacles or setbacks and is comfortable dealing with first- time or unusual challenges.

Education, Certifications and Experience:

Experience with payors and Clinical Guidelines or Medical Policy is preferred.

Conversant with medical and billing terminology.

Expertise and knowledge of third-party payor.

Computer and database management skills to efficiently and effectively manage proprietary electronic systems.

Interpersonal and communication skills to effectively deal with a variety of people, including physicians, hospital leaders, nursing staff, patients, and family members.

High School Diploma with 5+ years’ healthcare experience or an Associate's Degree in a healthcare-related field with 3+ years’ experience.

Physical Requirements:

As a remote-forward organization, this position operates in a professional office environment and teleworking from the employee’s home address listed in their employment file.

Prolonged periods of sitting at a desk and working on a computer

Keyboarding

Speaking

Must be able to lift up to 15 pounds at times.

Flexibility of working hours to support activities across multiple Time Zones.

Our PRO-spectus Culture Philosophy

At PRO-spectus we have created a culture that is supportive, dedicated, and teamwork driven. We celebrate each other’s joys in personal life and professional accomplishments, promoting meaningful relationships and friendships.

Our employees bring strength of mind and spirit to make the extraordinary happen every day. With humility and compassion at our core, PRO-spectus is proud of our relentless focus towards the higher purpose of improving the lives of patients we support.

We recognize it takes a lot of people working together with a common goal to make spectacular happen, and we never forget that at the heart of our company are the people who make it work.

PRO-spectus is an Equal Opportunity / Affirmative Action employer. All qualified individuals will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, protected veteran status, marital status or other protected status under federal, state or local laws.

At PRO-spectus, we are deeply committed to pay transparency and equity. The salary range for this position is $32.00 - $35.00 an hour, based on experience and qualifications, with the final offer reflecting skills and other job-related factors. Beyond competitive pay, we offer a comprehensive and generous benefits package designed to support your well-being and work-life balance.