Under the supervision of the Provider Reimbursement Supervisor, and in collaboration with Service Delivery Operations (SDO) staff, and other staff across all disciplines and departments, is responsible for reviewing processed claim runs from the TPA (Request For Funds, or RFFs), processing invoiced services from network providers, and for preparing system configuration documents for the TPA. Claim run and invoiced services reviews include communicating results and suggestions to providers, management, and the TPA. This position will support the implementation of changes to the CPT, HCPCS and ICD-10 codes on an annual and ad hoc basis. The Provider Relations Reimbursement Specialist works with SDO staff, TPA staff, and management to educate and service providers within established guidelines, and assures compliance with contract requirements.

This position is considered Hybrid, which means that individuals in this position may work both at an approved Offsite location and Onsite at a primary location or multiple locations based on Business Needs.  

Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without accommodations):
• Review of processed claim runs from the TPA (Request For Funds, or RFFs)
• Processing of invoiced services for proper coding, eligibility, appropriate services
• Identify coding discrepancies and formulate suggestions for improvement.
• Communicate audit results/findings to providers and/or ancillary staff (i.e. support, provider, coding, etc.) and share improvement ideas.
• Work with provider leadership to identify and assist providers with coding.
• Maintain confidentiality and adhere to all HIPAA guidelines and regulations.
• Strong attention to detail and accuracy.
• Excellent verbal and written communication skills.
• Excellent organizational skills.
• Ensure that all work is done in a timely and accurate manner.
• Proficiency in the use of computer and commonly used software including but not limited to Microsoft Office Suite.
• Attendance is crucial to position.
• Perform other duties as assigned.

Knowledge/Skills/Abilities:
• Develop and maintain favorable internal relationships, partnerships with co-workers.
• Ensure all actions, job performance, personal conduct and communications represent Central Health in a highly professional manner at all times.
• Uphold and ensure compliance and attention to all company policies and procedures as well as the overall mission and values of the organization.
• Ability to multi-task.
• Ability to provide data and recommend process improvement practices.

MINIMUM EDUCATION: Associate’s degree in related field

PREFERRED EDUCATION: Bachelor’s degree in a related field

MINIMUM EXPERIENCE: Minimum of 4 years of experience in medical office billing or payor of medical services claim environment.

PREFERRED EXPERIENCE: 4+ years of experience in medical office billing or payor of medical services claim environment

REQUIRED CERTIFICATIONS/LICENSURE: N/A

PREFERRED CERTIFICATIONS/LICENSURE: 

• Certified Professional Coder (CPC) or other recognized medical coding certification.
• Successful completion of a medical terminology course and coding specialist assessment are preferred

REQUIRED COURSES/COMPLETIONS (e.g., CPR): N/A