Reimbursement Specialist

At MIMEDX, our purpose starts with helping patients heal. We are driven by discovering and developing regenerative biologics utilizing human placental tissue to provide breakthrough therapies addressing the unmet medical needs for patients across multiple areas of healthcare. Possessing a strong portfolio of industry leading advanced wound care products combined with a promising clinical pipeline, we are committed to making a transformative impact on the lives of patients we serve globally.

POSITION SUMMARY:

Determine eligibility and benefits, answer billing questions, and obtain authorizations and predeterminations. Process insurance verification requests and secure prior authorization approvals for eligibility and benefit coverage. Answer questions as it relates to medical verifications of insurance policies, coding, billing, and claims. Conduct effective communications with the physician's office, Health Plan, and the Company's sales team. Follow all necessary policies, procedures, processes and systems in order to obtain accurate coverage information and optimize the maximum reimbursement levels.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Receive and process assigned clinical authorizations and insurance verification requests (IVR's) from data intake team
• Review IVR and correct data entry errors and omissions (e.g. incorrect Health Plan, missing information, etc.)
• Determine if payer already in database; if not, research payer on website to obtain demographic information and forward to senior team member for data entry
• Obtain benefit coverage levels and prior authorization requirements from Health Plan, submit required paperwork, and follow-up on coverage requests and prior authorizations
• Enter coverage levels and/or prior authorization requirements for assigned accounts in database
• Research and review electronically stored health policy notes and historical reimbursements, coverage information provided by Health Plan, and procedural information (e.g. diagnosis, product, place of service, etc.) from provider to aid in making accurate coverage determinations
• Analyze and interpret collected data, obtain additional information as needed, make coverage determination, and notify provider of decision
• Collaborate with sales and field reimbursement teams to get complete and correct information to process IVR's
• Respond to questions from physicians, hospitals, outpatient facilities/ambulatory care centers, etc. regarding billing, coding procedures, and processes
• Review and complete daily pending case reports to ensure prompt processing and closure of IVR's and authorization requests
• Identify and escalate issues as they may arise throughout the process; report IVR quality issues in an effort to minimize errors in processing and coverage determinations
• Follow HIPAA policies and procedures to ensure compliance
• Report changes/issues in coverage/reimbursement trends to management

EDUCATION/EXPERIENCE:

• BS/BA in related discipline. Certification may be required in some areas.
• 1-2 years of experience in related field, or verifiable ability,

OR

• MS/MA/MBA and 0-1 years of experience in related field
• 1-2 years of experience in insurance verification, billing/claims processing, data processing
• Good knowledge of medical coding including ICD10, CPT and HCPCS codes
• Good understanding of Medicare, Medicaid, and Commercial and health plans
• Good understanding of medical management, health insurance concepts, information systems
• Good understanding of HIPAA rules

SKILLS/COMPETENCIES:

• Excellent oral, written, and interpersonal communication skills
• Ability to interact with all levels of management, both internal and external, third party payers, and customers; with a focus on customer service
• Proficient in Microsoft Office (Excel, Word, etc.)
• Organized, flexible, and able to multi-task while maintaining a high level of efficiency and attention to detail
• Good analytical, problem solving, and trouble shooting skills
• Ability to make quick, sound decisions based on policy, past practices, and experience

WORK ENVIRONMENT:

The work is typically performed in a normal office environment. Will be assigned a pre-defined work shift based on current business needs.

Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to, or requirements for, this job at any time.