FIND YOUR FUTUREWe're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and commitment to diversity and inclusion.Overview Network Reimbursement Specialist-Senior is the corporate resource and subject matter expert in professional reimbursement and claim editing. The incumbent will ensure that all policies and processes that support physician, provider and ancillary agreements are consistent with reimbursement rules and proper coding standards. They must demonstrate the ability to make independent determinations on claims inquires and queue procedures based on their understanding of the requirements above. The Incumbent will serve as a reference for both internal and external customers regarding coding, policy and reimbursement issues and will provide support to the various committees, teams, and special projects. The Network Reimbursement Specialist-Senior will research industry and/or regulatory coding standards related to reimbursement methodology, billing practices, and coding rules. The Network Reimbursement Specialist-Senior will conduct analytic reviews to identify opportunities for process improvement and monitor reimbursement structure and reimbursement methodology.The Network Reimbursement Specialist-Senior's primary responsibilities will be in actions and tasks related to accurately reimbursing our practitioner community. The incumbent must be fluent in Independent Health reimbursement methodologies and show the ability to research and obtain relevant information needed to support the department initiatives. Additionally, the Network Reimbursement Specialist-Senior will be required, when needed, to represent the department on cross-functional teams and provide valuable information and follow-up. The incumbent must clearly understand our business mission and actively engage with other departments to assist in matters of reimbursement and develop/operationalize processes.Additionally, the incumbent will be required to have a comprehensive understanding of our claims editing software and will have the ability to maintain the software with configuration modifications. The incumbent will be required to triage questions pertaining to edits, possess the skill set to build and maintain rules, and be an active participant in the claims editing system updates and upgrades. They will also be required to build complex test cases to validate updates and upgrades of our editing system to ensure changes are in-line with Independent Health policies and procedures. The incumbent will also be required to support the department via completion of Service Requests pertaining to professional reimbursement and claims editing, as well assist in Network Requirement Queues if needed. Associate specific responsibilities will be outlined and based on the current business need of the department. The incumbent will also be responsible for working independently with other department to resolve billing, coding, editing and reimbursement issues that may pertain to professional claims.Qualifications High School diploma or GED required; Associates degree preferred.Three (3) years of reimbursement experience in the healthcare industry required with expertise in industry standard claims edits and correct coding requirements.Has obtained and maintained the certification of Certified Professional Coder, American Academy of Professional Coders.Strong working knowledge of CPT, ICD-9-CM, ICD-10-CM and HCPCS coding systems.PC and Windows skills including Microsoft Word, Excel, Access, and Internet navigation skills.Strong analytical skills.Proven ability to assume responsibility and work independently.Ability to accomplish daily tasks with little to no direct oversight. Ability to represent the department at cross-functional teams and engage meaningfully. Effective written and verbal communication skills.Ability to maintain confidentiality.Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.Essential Accountabilities Comprehensive understanding of Independent Health reimbursement policies and professional reimbursement methodologies and the ability to independently apply that understanding to matters of reimbursement, claim adjudication, bundling and claims editing.Research, analyze and resolve complex professional practitioner processing issues and when needed collaborate with Provider Relations Associates to resolve said issue.Exercise independent judgment in claims processing determinations when working queues and Service Requests.Conduct self-directed research and claim reviews to audit proper application of reimbursement policies and independently take corrective action based on results.Assist in the implementation of professional practitioner fee schedules and ensure their accuracy.Develop and maintain professional reimbursement SOPs, documented processes, and decision-making trackers.When required, work directly with software vendors to test, and resolve issues as identified above maintaining documentation of all issues from date of identification through resolution including all test case scenarios for new rule creations.Running claim queries to support adjustment requests and analytics.Understand in detail and keep abreast of changes to industry standard coding guidelines and professional reimbursement rules and innovative models and methodologies. Maintain Certified Professional Coding status through participation in the Continuing Education seminars.Contribute to and assist in updating the corporate Participating Practitioner Reimbursement Manual.As directed, actively represent Network Reimbursement on teams and projects.As directed, work independently with IT to coordinate updates and upgrades to the claims editing system.Review claims editor update release notes to assess changes and impacts; make recommendations to management regarding financial impact to the professional practitioner community.Development of complex claim editing test cases to test quarterly/off-cycle updates and validating system upgrades prior to Production environment changes. Analyze the test results and effectively communicate with management and internal stakeholders if resolution is required.Test and validate software upgrades to ensure correct claims editing in Production.Support the department via answering Service Requests and servicing internal customers with questions related to Network Reimbursement or claims editing.Assist in the establishment of reimbursement policies and rules consistent with correct coding guidelines.Collaborates with associates on the Facility Reimbursement team to ensure consistent processing of services.Recommend and assist in the implementation of process improvements that lead to administrative savings and efficiency for the department.Actively participate in knowledge sharing and educational presentations with other team members at departmental meetings and assist in training and mentoring associates when needed.Immigration or work visa sponsorship will not be provided for this positionHiring Compensation Range: $60,500 - $70,000 annuallyCompensation may vary based on factors including but not limited to skills, education, location and experience. In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here for additional EEO/AAP or Reasonable Accommodation information.Current Associates must apply internally via the Job Hub app. As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here: https://www.independenthealth.com/AboutIndependentHealth/Careers/AdditionalEEO-AAPInformation for additional EEO/AAP or Reasonable Accommodation information.Minimum Salary: 31200.00
Maximum Salary: 31200.00
Salary Unit: Yearly
