Reimbursement Specialist ll

About AmeriPharma

AmeriPharma is a rapidly growing healthcare company where you will have the opportunity to contribute to our joint success on a daily basis. We value new ideas, creativity, and productivity. We like people who are passionate about their roles and people who like to grow and change as the company evolves.

AmeriPharma’s Benefits

• Full benefits package including medical, dental, vision, life that fits your lifestyle and goals
• Great pay and general compensation structures
• Employee assistance program to assist with mental health, legal questions, financial counseling etc.
• Comprehensive PTO and sick leave options
• 401k program
• Plenty of opportunities for growth and advancement
• Company sponsored outings and team-building events
• Casual Fridays

Job Summary
We are seeking a highly organized Reimbursement Specialist II to join our dynamic team. The ideal candidate will be responsible for ensuring accurate and timely collections to maximize reimbursement, which includes interactions with third-party payers, insurance plans, and patients.

Schedule Details

• Location: On-Site (Laguna Hills, CA)
• Hours: Monday to Friday, 8:00 AM - 4:30 PM

Duties and Responsibilities

• Review patient inventory for assigned accounts.
• Verify accuracy of claims submitted and communicate with team members and management on process inefficiencies or billing errors resulting in claim denials or underpayments.
• Verify newly submitted claims status to ensure claims are on file with insurance, are in process, and hold payers accountable for accurate and timely reimbursement.
• Review accuracy of claim payments received from payers and patients.
• Identify and promptly communicate inadequate reimbursement rates to management, potentially requiring pharmacy transfer.
• Submit appeals and pursue additional payments on medical claims denied in error or paid less than the expected reasonable maximum allowable rate for procedure codes and patient benefit levels.
• Submit negotiation letters and obtain payment resolutions from claim payers.
• Perform collections on patient balances to ensure maximum reimbursement for services provided.
• Ensure proper submission of complete clinical documentation to justify claims' medical necessity.
• Independently perform claims follow-up and collections activities, including resolving claim denials and rejections via resubmissions, corrected claims, and appeals, following Billing Department’s approved reimbursement strategies.
• Review and interpret benefit details, identifying inaccuracies affecting claims reimbursement, and communicate these discrepancies to the appropriate parties.
• Document claim statuses accurately and timely on each patient account (new or existing).
• Create and use reminders and follow-up reports to ensure completion of pending activities.
• Escalate unresolved claim issues to management after proper resolution attempts.
• Maintain a positive DSO (Days Sales Outstanding) on assigned account inventory.
• Provide the highest level of customer service in handling patient calls, resolving billing issues, and communicating with doctors’ offices and staff.
• Identify and communicate any issues with incomplete or inaccurate billing databases leading to errors or delays.
• Assist in account collections activities as needed.
• Ensure compliance with payer rules, regulations, and company policies and procedures.
• Perform other duties as assigned by management.

Required Qualifications

• Proficient in reading, writing, speaking, and understanding English.
• Ability to collaborate and cooperate with team members and management.
• Strong time management, communication, interpersonal, multi-tasking, and prioritization skills.
• Excellent interpersonal and service-oriented skills.
• Ability to work independently with minimal guidance.
• Strong attention to detail with the ability to type accurately and analyze data.
• Ability to apply logical thinking to solve complex and practical problems.
• Flexible and able to work hours that ensure timely completion of projects and duties.

Education and Experience Requirements

• High School Diploma or equivalent.
• 2-3 years of collections and reimbursement experience, with knowledge of managed care and commercial insurance.
• Knowledge of ICD-10, CPT, HCPC, J billing codes, and medical terminology, along with CMS HCFA 1500 form & Electronic Billing.
• Familiarity with Benefit Investigation and Patient Responsibility Agreements.
• Experience with automated billing systems, CPR preferred.
• Advanced proficiency in Word, Excel, and Outlook.

AmeriPharma’s Mission Statement 

Our goal is to achieve superior clinical and economic outcomes while maintaining the utmost compassion and care for our patients. It is our joint and individual responsibility daily to demonstrate to outpatients, prescribers, colleagues, and others that We Care!

Physical Requirements 

The following physical activities described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions and expectations

EEO Statement 

The above statements are intended to describe the work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required. The duties and responsibilities of this position are subject to change and other duties may be assigned or removed at any time. AmeriPharma values diversity in its workforce and is proud to be an AAP/EEO employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, sexual orientation, gender identity, national origin, age, protected veteran status, or on the basis of disability or any other legally protected class.

Salary : $29 - $33