Reimbursement Specialist

UPMC•Harrisburg, PA

11h

About The Position

UPMC Corporate Pharmacy is hiring a Reimbursement Specialist to review patients requiring chemotherapy and adjunctive infusions. The Specialist confirms insurance benefits and reimbursement, determines patient financial responsibility, and communicates findings to patients and the clinical team. The role also reviews open accounts, evaluates claim status, intervenes to support appropriate payment, and helps patients identify oncology-specific assistance programs. The position works Monday through Friday, 8:00 AM to 4:30 PM EDT. Responsibilities span insurance account management, financial and coding issues, and patient account management. The Specialist researches and resolves claim issues, supports accurate billing and reimbursement, works with clinical and administrative stakeholders, and assists patients with authorizations, benefit questions, financial assistance, and billing inquiries.

Requirements

High school graduation.
Good mathematical skills.
Accuracy and attention to detail.
At least two years of experience in insurance verification, claim adjudication, medical office billing, or outpatient billing.
Act 34 clearance.

Nice To Haves

Proficiency in Microsoft Word and Microsoft Excel.
Oncology experience.
Knowledge of medical terminology, ICD-9, and CPT coding.
Understanding of insurance policies and procedures.

Responsibilities

Demonstrate problem-solving, verbal and written communication, adaptability, professionalism, commitment to patient care, and respect for individual dignity and diversity.
Maintain positive working relationships within the department and with other areas, community members, and outside agencies.
Prepare assigned financial reports.
Research insurance rejections and claim problems; resubmit or appeal claims where appropriate and monitor appeals through payment.
Review older invoices for problems and possible resubmission; review denial trends and work with insurers to resolve payment issues.
Communicate front-office-related issues to departments and maintain current knowledge of insurance policies, procedures, billing information, and contacts.
Abstract medical-record data for billing, medical necessity, and reimbursement, and work with the Director of Payer Relations to identify services not adequately addressed in payer contracts.
Assign diagnosis and procedure codes according to ICD-9-CM and CPT guidelines; enter or review outpatient charges and bills in the applicable systems.
Verify supporting documentation and review charges for coding, completeness, demographic accuracy, and insurance-data accuracy.
Audit insurance payments against contractual amounts and maintain knowledge of coding standards and guidelines.
Coordinate with department leaders, physicians, clinical staff, patient accounting, scheduling, and other stakeholders on coding and reimbursement accuracy.
Assist with education for physicians and others on identified coding and billing issues.
Compare hospital and physician-practice treatment to evaluate reimbursement and patient responsibility for planning.
Obtain detailed benefit information, including hospital- and practice-side coverage, and identify ways to maximize plan benefits.
Obtain payer-specific predetermination and prior-authorization procedures and documentation requirements; facilitate authorizations when applicable.
Determine medical necessity using current policies and stay informed about insurers’ clinical bulletins.
Collect applicable coinsurance and deductibles and update patient account information.
Review uninsured accounts and verify medical assistance, charity care, or drug replacement program options; follow up on potential bad-debt liabilities.
Communicate patient financial responsibility and help establish next steps, including assistance applications, payment plans, or education about insurance benefits and compliance expectations.
Work with patients to complete required Medical Assistance paperwork and resolve patient billing inquiries.
Evaluate eligibility for free medication based on diagnosis, insurance, and financial information; obtain required consent and documentation.
Identify patients eligible for copay assistance and facilitate the application process.
Identify inadequate reimbursement or significant patient responsibility for oncology-specific drugs and coordinate with the patient's specialty pharmacy to obtain the drug as appropriate.