Reimbursement Specialist

• Follow standard operating procedures to obtain and process manufacturer copay assistance program reimbursement
• Monitor claims activity for accuracy and successful submission
• Ensure patient billing information is set up appropriately in pharmacy software
• Participate in conferences and meetings related to reimbursement/billing
• Respond to employee, patient, and client questions or complaints regarding reimbursement and/or billing
• Work with internal teams to review and resolve claim issues
• Maintain accurate reference information relating to reimbursement and copay assistance
• Document information, insurance, and prescriptions/orders accurately and thoroughly within patient profiles
• Comply with applicable federal and state laws and ethical standards
• Perform other duties as assigned

Reimbursement Specialist I

• Handle all patient billing and collections
• Collect third-party payor accounts for assigned payers
• Follow up on revenue-cycle reimbursement matters, including projects, issue escalation, denials management and research
• Maintain and update shared documentation on insurance policies, rules and limitations
• Identify adjustments, payment trends and denials and escalate problems as necessary
• Communicate changes regularly or as needed
• Collaborate with Intake and Reauthorization Specialists to ensure timely collections
• Assist the PBM and Billing Specialist with issues, billing backlogs and end-of-month processes
• Field and troubleshoot patient calls regarding benefits, claims and balances
• Proactively resolve billing issues
• Perform CPR+/Caretend transactions accurately and timely
• Document and input new referrals and subsequent patient admissions from start to finish according to PromptCare policies and procedures
• Perform other duties as assigned

• Resolve billing-related inquiries from patients, providers, and other internal customers through inbound calls.
• Engage with patients via telephone, email, and live chat.
• Support clinicians, insurers, and the management team to facilitate prompt account collections.
• Work aged accounts.
• Research and reconcile credit balance accounts and process adjustments as needed.
• Review patient insurance coverage for genetic testing.
• Document activities appropriately in process notes.
• Participate in the Quality Assurance plan.
• Comply with applicable CLIA and HIPAA regulations.

Reimbursement Specialist – Patient Accounts

• Handle all patient billing and collections
• Complete documentation and computer input for new referrals and subsequent patient admissions from start to finish
• Collect third-party payor accounts for assigned payers
• Follow up on revenue cycle reimbursement activities, including projects, issue escalation, denials management, and research
• Maintain and update shared documentation for the Intake Team regarding insurance policies, rules, and limitations
• Identify adjustments, payment trends, and denials and escalate problems as necessary
• Communicate changes regularly or as needed
• Collaborate with Intake and Reauthorization Specialists to ensure timely collections
• Assist the PBM and Billing Specialist with issues, billing backlogs, and end-of-month processes
• Handle and troubleshoot patient calls regarding benefits, claims, and patient balances
• Proactively resolve billing issues
• Perform CPR+/Caretend transactions accurately and timely
• Perform other duties as assigned

• Monitor, assess, and report on provider, payor, and legislative trends and developments
• Manage day-to-day reimbursement activities to achieve key business objectives
• Maintain existing reimbursement services and develop new ones
• Work cross-functionally with Ossur’s Chronic Solutions Business Area to develop new reimbursement services and training for targeted customers
• Increase customer recognition of the companies as providers of industry-leading reimbursement resources
• Provide external customers with support on reimbursement questions about Ossur products
• Develop reimbursement materials regarding company products for customers
• Assess and implement reimbursement programs, resources, and services supporting customers
• Assist customers in obtaining authorization and writing appeals
• Update Sales & Marketing staff regarding payor policy changes affecting customer access to products
• Work cross-functionally with product management on reimbursement issues and submissions to government contractors such as PDAC
• Participate in DME MAC Advisory Council meetings
• Attend DME MAC educational meetings
• Maintain compliance with company quality, safety, training, and values requirements

• Provide inbound and outbound phone support as the primary contact for patients, caregivers, and providers
• Coordinate and monitor patient needs throughout the Patient Support Program journey
• Handle day-to-day reimbursement services activities
• Interact with healthcare insurance companies to verify financial aspects of healthcare services
• Advise patients on eligibility requirements, program enrollment, reimbursement processes, affordability support, and therapy access
• Establish relationships and maintain rapport with patients, payers, and healthcare providers
• Provide ongoing support and program information to healthcare providers
• Verify insurance coverage, medical billing, reimbursement processes, and access for complex pharmaceuticals
• Evaluate program enrollment forms for data integrity
• Conduct insurance benefit investigations and triage cases according to standard operating procedures
• Follow program guidelines and escalate complex cases according to policies, SOPs, Call Guides, and program materials
• Maintain case records and document status and background in the case management system
• Communicate patient benefits and assist with prior authorization and appeals processes
• Explain benefits offered by private/commercial and government payers, including Medicare, Medicaid, VA, and DOD
• Liaise with client contacts, Program Management, internal stakeholders, and healthcare providers
• Maintain records according to applicable standards and regulations
• Serve as a brand advocate and program representative while delivering customer service and quality outcomes
• Collaborate with the Program Manager regarding patient status, prescriber feedback, satisfaction, and program effectiveness
• Maintain confidentiality and privacy
• Meet training deadlines and follow all SOPs
• Perform additional assigned tasks or projects

• Perform daily deposit tracking, pull missing EOBs, load them into Fuse, manually match ERA/deposits in Fuse, and reconcile daily deposits in Remit Assist
• Review, research, and resolve tasks related to missing payments, EOBs, and posting errors in the Raintree system
• Support the month-end reconciliation process
• Perform accurate and timely payment posting
• Handle payment posting in Raintree and assigned legacy systems, including remittance/automated posting, manual posting, refunds, and corrections
• Identify and escalate issues to leadership in a timely manner
• Complete ad hoc projects, reporting, and analysis
• Perform other duties as assigned

• Compile, analyze, and report on departmental operating-unit performance
• Analyze departmental-specific reports and provide feedback
• Ensure accurate and compliant charge items and resolve billing inconsistencies using clinical and coding knowledge
• Coordinate projects and audits to improve revenue-cycle processes, charging and billing efficiency, and collection efforts
• Provide historical information to assist management with forecasting
• Work with departmental directors, managers, and personnel to ensure budgetary compliance
• Manage accounts-receivable and/or financial-reporting systems
• Prepare reports and analyses for PRMO, DUHS, and PDC leadership
• Coordinate communication among insurance companies, governmental agencies, providers, and support staff
• Trend and report departmental performance indicators and goals
• Recommend improvements to financial systems and conduct in-house operating-unit audits
• Assist with departmental goal and objective development
• Manage and delegate database inquiries when applicable
• Create work assignments and train employees
• Maintain professional relationships with internal and external agencies and professional organizations
• Serve as liaison between physicians and the PRMO when applicable
• Conduct employee quality reviews and provide feedback to management and employees when applicable
• Develop and provide job-specific training
• Perform other related duties

Reimbursement Specialist – Outpatient Medication Authorization

• Compile, analyze, and report on departmental operating-unit performance
• Analyze departmental reports and provide feedback
• Ensure accurate and compliant charge items and resolve billing inconsistencies
• Coordinate projects and audits to improve revenue-cycle, charging, billing, and collection processes
• Assist management with forecasting using historical information
• Work with directors, managers, and relevant personnel to ensure budgetary compliance
• Manage accounts-receivable and/or financial-reporting systems and prepare reports and analyses for PRMO, DUHS, and PDC leadership
• Coordinate communication among insurance companies, governmental agencies, providers, and support staff
• Track and report departmental performance indicators and goals
• Recommend improvements to financial systems and conduct operating-unit audits
• Help develop departmental goals and objectives
• Manage and delegate database inquiries when needed
• Create work assignments and train employees
• Maintain relationships with internal and external agencies and professional organizations
• Serve as liaison between physicians and the PRMO when needed
• Conduct employee quality reviews and provide feedback to management and employees
• Develop and provide job-specific training
• Perform other related duties