Specialty Medication Reimbursement Specialist

Description

About CLS Health

CLS Health is a growing healthcare system in Houston, Texas that is taking a different approach to healthcare. We are a physician-led healthcare group that focuses on providing patients with holistic, multispecialty care. We're a dynamic team on a mission to provide better healthcare options for Houstonians!

Position Summary

Audits infusion and specialty medication claims to find out what got paid, what didn't, and why, then fixes the root cause. This role works payers, manufacturer programs, and internal billing to recover revenue and prevent repeat denials.

Responsibilities:

• •Monitor unbilled and unpaid infusion and specialty medication encounters and keep claims moving to timely submission
• •Audit paid claims against expected reimbursement using payer fee schedules and drug allowables (ASP, WAC, contracted rates)
• •Work denials and underpayments and identify the cause: authorization, benefits or site-of-care restriction, coding or NDC/unit errors, documentation gaps, or copay assistance that was never reimbursed
• •Call payers to confirm coverage, fee schedule, and buy and bill vs specialty pharmacy requirements for specific medications
• •Reconcile copay card and foundation assistance payments and follow up on outstanding manufacturer reimbursements
• •Coordinate corrections and rebills with billing and the intake team, and feed findings back into the intake process so the same denial doesn't recur
• •Report payer and drug-level profitability and denial trends to the Ancillary Services Manager

Benefits:

• •401(k) matching
• •Dental Insurance
• •Disability insurance
• •Health insurance
• •Life insurance
• •Paid time off

Requirements

• •3+ years in medical billing, reimbursement, or revenue cycle with direct experience in infusion or specialty drug claims
• •Working knowledge of J-codes, NDC and unit billing, buy and bill, specialty pharmacy, and medical vs pharmacy benefit
• •Able to read payer policies, fee schedules, and EOBs and explain a denial in plain terms
• •Experience with copay assistance and manufacturer reimbursement reconciliation
• •Comfortable with Excel and payer portals; Power BI or reporting experience is a plus
• •Coding certification (CPC or similar) is a plus