Reimbursement Specialist II – Follow-Up, Appeals

This is a fully remote position, open to applicants in United States.

📋 Description

• Analyze and interpret EOB/ERA files to uncover claim denials, errors, and underpayments.

• Prepare and submit appeals for non-covered services, low payments, and contested claims.

• Facilitate positive coverage determinations through external appeals.

• Escalate intricate payment issues to guarantee timely resolutions.

• Monitor, report, and manage complex outstanding claims.

• Maintain records of payer communications, claim statuses, correspondence, and research efforts.

• Offer reimbursement assistance and customer service to patients and their families.

• Verify and communicate insurance eligibility, billing, collections, and payment responsibilities.

• Accurately input and document account information in computer systems.

• Manage incoming correspondence via fax, email, and portals, associating it with patient and insurance records.

• Communicate with payers and internal stakeholders through email, fax, and other communication channels.

• Handle inbound and outbound calls concerning payment statuses and claim issues.

• Identify and report trends among payers.

• Utilize spreadsheets for data analysis and reporting purposes.

• Participate in training and educational programs for role-related software and systems.

• Manage time effectively while maintaining accuracy in reimbursement and cash application tasks.

• Collaborate across functions to identify and address claims adjudication and ASP inefficiencies.

• Investigate and resolve credit balances, missing payments, payment allocations, and discrepancies in claims or appeals.

• Participate in corporate events, meetings, conferences, development opportunities, and in-person team-building activities as required.

• Perform other assigned responsibilities.

⛳️ Requirements

• A minimum of 3-5 years of recent experience in both professional and facility healthcare claims posting.

• Knowledge of health plan regulations and processes involving high volume and/or multiple accounts.

• Experience in contacting and following up with national and regional insurance carriers.

• Proficiency in handling denials, reconsideration requests, formal appeals, and negotiations.

• Experience appealing to state-level agencies or external-level reviews with IRO/IRBs.

• Strong mathematical abilities and the capacity to read and understand EOBs.

• Familiarity with revenue cycle tools and laboratory reimbursement workflows.

• Experience in EDI enrollment and management of payer portals.

• Knowledge of Telcor, Waystar Clearinghouse, and Sarbanes-Oxley controls (SOX) is highly desirable.

• Demonstrated cross-functional collaboration with internal teams and external stakeholders.

• Strong attention to detail, self-motivation, organizational skills, and a focus on process improvement.

• Proficiency with computer hardware, PC software, Microsoft Office Suite, Adobe Acrobat PDF, and Excel.

• Above-average typing skills.

• An analytical mindset with experience in data analysis and process optimization.

• Capability to work independently while managing confidential and sensitive information.

• Ability to work effectively in a team-oriented environment.

• Excellent communication and interpersonal skills.

• Ability to critically assess and responsibly utilize AI-enabled tools in accordance with company policies, ethical standards, and regulatory requirements.

• Must maintain confidentiality and comply with HIPAA guidelines/regulations.

• A background screening, including criminal history, is required.

🏝️ Benefits

• Hybrid work model for eligible onsite employees, including work-from-home days.

• Participation in corporate events and quarterly/biannual/annual meetings.

• Opportunities for development and attendance at conferences.

• Team-building activities.

• Reasonable accommodations during the hiring process.

• Confidential handling of applicant information.