Job Information
UPMC Reimbursement Specialist in Harrisburg, Pennsylvania
The Renal Transplant-Kidney department is looking for a new Reimbursement Specialist to join their team. This position will be patient facing on a day-to-day basis. They will coordinate with patients to ensure that they have all relevant transplant insurance and prescription coverage for the transplant.
Schedule: Three day per week, hours will most likely be from 7:30 a.m. – 4:00 p.m., possible flexibility.
Hours of operation for the office: 7:30 a.m. – 4:00 p.m.
Purpose:
Responsible for review of all patients requiring chemotherapy and adjunctive infusions, including confirmation of patient insurance benefits, reimbursement, and determination of any patient responsibility. Communicates findings with clinical team and patient. Reviews open accounts to evaluate claim status and intervenes appropriately to assure proper payment. Works with patients to determine availability of oncology specific assistance programs.
Responsibilities:
Performs other duties as assigned
Demonstrates effective problem-solving, an ability to communicate verbally and in writing, and a willingness to adapt to changing environment.
Promotes and maintains positive working relationships within the department and with other areas throughout PinnacleHealth, the community and outside agencies.
Demonstrates professionalism with fellow employees, providers, and patients in person, on the telephone, and in writing.
Demonstrates by his/her own behavior a strong sense of commitment to patient care.
Demonstrates respect for individual dignity and diversity.
Insurance Account Management:
Research's rejections and investigates problems, resubmitting and/or appealing claims where appropriate.
Periodically monitors progress of appealed claims and communicates provider representative until claim is paid appropriately.
Provides additional information as needed to facilitate payment.
Reviews claim denial trends and communicates with the insurance companies as appropriate to resolve issues that may prevent payment for services.
Possesses knowledge of insurance policy, guidelines, and referral/authorization processes.
Maintains up to date information on insurance policies and procedures, billing information, and contacts.
Abstracts data from medical records to provide accurate and timely information for billing, medical necessity, and reimbursement.
Financial Issues:
Assigns codes to diagnosis and procedures according to the ICD-9 CM and CPT guidelines.
Enters or reviews outpatient charges using appropriate diagnosis codes and modifiers.
Verifies that all charges have supporting documentation.
Reviews charges for correct coding, completeness and accuracy of demographic and insurance data.
Maintains knowledge of coding standards and guidelines.
Works closely with clinical staff, physicians, other department stakeholders, patient accounting and scheduling areas.
Assists Supervisor/Director with ongoing education to physicians and others as it relates to identified issues with coding and billing.
Patient Account Management:
Must have a solid working knowledge of insurance plans and benefit structures on both the hospital and practice side, in order to obtain detailed benefit information and maximize plan benefits.
Obtains payor specific pre-determination and/or prior authorization procedures and documentation requirements.
If applicable facilitates the prior authorization process for patients and healthcare providers.
Determine medical necessity based on current policies and stays updated on clinical bulletins with individual insurance carriers.
Reviews accounts without insurance, verifies MA application process, charity care application and/or drug replacement program availability.
Communicates with patient regarding financial responsibility to establish a course of action either from the standpoint of applying for medical assistance, setting up a payment plan, or educating them on the compliance and expectations related to other insurance benefits.
Updates patient account information as required.
Familiar with the specific health care benefits of each of the Medical Assistance insurers.
Receives and resolves patient billing inquiries.
Evaluates eligibility for patient to receive free drug based on diagnosis, insurance, and financial information.
Identify patients eligible for co-pay assistance based on diagnosis and financial information.
Facilitate application process with patient.
Identify insufficient reimbursement or significant patient responsibility for transplant specific drugs.
Communicate with patients Specialty Pharmacy to order and obtain the drug as appropriate.
High school graduate with good mathematical skills.
Requires accuracy and attention to detail.
Two to three year's experience in insurance verification, claim adjudication, medical office billing or outpatient billing.
Preferred Knowledge, Skills and Abilities:
Proficiency in Microsoft Word and Microsoft Excel.
Experience in oncology preferred.
Knowledge of medical terminology, ICD-9 and CPT coding preferred.
Understanding of insurance policies and procedures preferred.
Licensure, Certifications, and Clearances:
- Act 34 with renewal
UPMC is an Equal Opportunity Employer/Disability/Veteran