Insurance (1)

Account Reimbursement Specialist III

Job Summary:
The Account Reimbursement Specialist III is an advanced-level revenue cycle professional and subject matter expert responsible for complex insurance account reimbursement, denial resolution, claim follow-up, and payer-related research. This role demonstrates a high level of expertise in physician practice billing, payer reimbursement methodologies, claim requirements, appeals, payment variance analysis, and regulatory guidelines.

The Account Reimbursement Specialist III is responsible for resolving complex, high-dollar, aged, and escalated accounts that require advanced research and payer intervention. The position serves as a resource and subject matter expert for Account Reimbursement Specialists and other RCM team members, providing guidance on complex reimbursement issues, payer policies, denial resolution strategies, and claim correction requirements.

This role also identifies systemic reimbursement issues and denial trends, performs root-cause analysis, and partners with RCM leadership and operational teams to implement solutions that improve reimbursement, reduce preventable denials, and strengthen revenue cycle performance. The Account Reimbursement Specialist III is a key contributor to maximizing net collections and ensuring accurate and timely reimbursement.

Primary Job Responsibilities:

Performs all responsibilities of the Account Reimbursement Specialist I and II positions.
Serve as a subject matter expert (SME) for complex account reimbursement, payer requirements, denial resolution, claim follow-up, appeals, and reimbursement issues.
Manages and resolves complex, high-dollar, aged, and escalated insurance accounts requiring advanced investigation and payer intervention.
Performs advanced research of payer policies, contracts, medical necessity requirements, reimbursement guidelines, claim processing rules, and payer-specific requirements to determine appropriate resolution strategies.
Analyzes complex Explanation of Benefits (EOBs), remittance advice, payment discrepancies, contractual adjustments, bundling issues, underpayments, overpayments, and non-payment scenarios to determine appropriate account resolution.
Develops and submits complex reconsiderations, appeals, medical necessity appeals, corrected claims, and other payer disputes when appropriate to secure maximum reimbursement.
Conducts detailed claim research across payer portals, payer correspondence, medical records, claim history, authorization information, coding, charge capture, and other available documentation.
Resolves difficult denials, including but not limited to medical necessity, bundling, authorization, eligibility, timely filing, coding, modifier, coordination of benefits, non-covered services, contractual, and payer processing issues.
Identifies accounts requiring escalation and appropriately coordinates with RCM Leadership, coding, to achieve resolution.
Tracks and follows complex accounts through multiple levels of payer review and escalation, maintaining detailed documentation of actions taken, payer responses, and required next steps.
Serves as an escalation resource for Specialist I and II staff by providing guidance on complex accounts, payer policies, denial resolution, and appropriate follow-up strategies.
Provides peer-to-peer coaching and knowledge sharing to RCM team members on complex reimbursement issues, payer changes, denial trends, and best practices.
Identifies opportunities for recovery of previously denied, underpaid, or incorrectly processed claims and develop strategies to pursue additional reimbursement.
Assists with developing and maintaining payer-specific workflows, denial resolution guidelines, reference materials, and other RCM resources.
Supports training and onboarding of new and existing RCM team members by providing subject matter expertise and guidance on complex reimbursement functions.
May perform quality reviews of account reimbursement activities to identify training opportunities, documentation gaps, or process inconsistencies.
Performs patient and insurance payer outreach to research and resolve complex payment-related inquiries and Athena patient accounts.
Maintains accurate and comprehensive account documentation in accordance with departmental standards.
Meets established productivity, quality, follow-up, and cash collection expectations.
Maintains current knowledge of payer policies, reimbursement methodologies, medical billing requirements, and applicable regulatory changes.
Perform other duties and special projects assigned.

Requirements:

Minimum of five (5) years of progressive and complex healthcare revenue cycle, medical billing, or insurance reimbursement experience in a physician office, ambulatory surgery center, or centralized medical business office.
Strong knowledge of physician practice billing, claim submission requirements, payer processing rules, and accounts receivable follow-up.
Strong understanding of medical terminology, ICD-10, CPT, HCPCS, modifiers, and common coding-related reimbursement issues.
Strong analytical and problem-solving skills with the ability to identify root causes and develop appropriate resolution strategies.
Ability to research payer policies and apply guidelines to individual account situations.
Demonstrated ability to work independently and exercise sound judgment on complex accounts.
Ability to serve as a resource and mentor to less experienced team members without direct supervisory responsibility.
Excellent verbal and written communication skills.
Strong customer service and professional communication skills.
Excellent computer skills, including Microsoft Word and Excel.
Experience with Athenahealth/AthenaOne preferred.
Ability to manage multiple priorities, organize daily workload, and meet established productivity, quality, and accuracy standards.

Education and Certifications

High school diploma or equivalent required.
Associate degree in Business, Healthcare Administration, Medical Billing, Revenue Cycle Management, or related field highly preferred.

Physical Requirements

Work consistently requires walking, standing, sitting, lifting, reaching, stooping, bending, pushing, and pulling.
Must be able to lift and support weight of 35 pounds.
Ability to concentrate on details.
Use of computer for long periods of time.

Account Reimbursement Specialist 3

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