Payment Integrity And Refund Specialist

KabaFusion•Cerritos, CA

23h

About The Position

This position is responsible for ensuring accurate and compliant billing processes across Government, Commercial Health Plans, and Medical Group payers while managing claims resolution and refund processing. The position also involves analyzing payer correspondence, escalating trends, maintaining contractual compliance, and addressing reimbursement issues promptly.

Requirements

High School Graduate or Equivalent.
Minimum of one (1) year of experience in home infusion.
Proficient experience with Microsoft Office including Word, Excel, Outlook, Teams, and/or electronic health care record software system preferred.
Knowledgeable of HCPC and CPT codes.
Demonstrate the ability to prioritize and meet goals and deadlines.
Demonstrate strong attention to detail and productivity standards.
Demonstrate the ability to work with minimal supervision.
Demonstrate strong understanding of insurance terms, medical terminology, pricing methodology for commercial and government billing requirements.

Responsibilities

Assures billing processes are compliant with payer requirement for Government, Commercial Health Plans and Medical Group payers.
Escalate credits to Level II Payment Integrity/Refund Representative, Sr. Payment Integrity/Refund Representative and/or upper management when seeing a trend by payer.
Analyze and rectify claims issues with payers by timely follow up of correspondence/ refund letters received from payers.
Reviews and assures claims are processed and paid in full according to contractual agreements.
responsible for accurate and timely follow up when processing payer and patient refunds, including submitting refund requests forms to Reimbursement Supervisor for review.
Ensures revenue is booked according to appropriate contract allowable.
Communicates and addresses reimbursement issues with Lead/Supervisor for resolution in a timely manner.
receiving correspondence and documenting on the Refund Request Log, as well as scanning in document manager.
Handles calls regarding refund requests promptly with professionalism to payers.
Ensures daily productivity is met, minimum of 30-35 claims worked per day.
Other related duties as assigned by manager or designee.