2,146 Reimbursement jobs in the United States

The primary function of the Medical Reimbursement Specialist is the resolution of open insurance balances through collections. The position is responsible for researching unpaid, underpaid and denied insurance claims then applying contractual billing and payment guidelines to ensure timely resolution and meet collection goals.

• Facilitate resolution of open receivables by review of coding, billing, contract agreements , and authorization terms.
• Diagnose and report issues with regards to rejection and denial trends to management
• Maintain accurate documentation of claim follow up activities.
• Address inquiries on customer service encounters to include, but not limited to process requests for adjustments, account type changes, guarantor merges, and transfers when necessary, according to enterprise guidelines.
• Address insurance denials and underpayments, appealing and/or adjusting balances as appropriate and accurately billing the guarantor for patient responsibility.
• Accurately enter patient demographics, guarantor, and coverage information into Epic system.
• Accurately change filing order, ensure necessary adjustments are listed on account, distribute payments to correct service dates and request changes if needed.
• Know and use standard business practices, keep abreast of all insurance and system changes, demonstrate excellent customer service that promotes patient, staff, and customer satisfaction, and reflects the Mission, Vision, and Values of Nemours.
• Attend meetings regarding assigned Payors, team/department updates, etc.
• Assist insurance companies/guarantors with questions regarding charges and balances.
• Work with other departments to resolve issues affecting reimbursement.
• Other duties as assigned.

• High School Diploma required.
• Minimum 1 year of experience required.

• Processes and verifies reimbursement claims, ensuring accuracy and compliance with payer guidelines and regulatory requirements.
• Reviews and resolves claim discrepancies, identifying incorrect payments, denials, or underpayments and taking appropriate action.
• Applies correct transaction codes to accounts, ensuring proper claim adjudication and reimbursement flow.
• Monitors and follows up on outstanding claims, ensuring timely resolution and payment collection.
• Collaborates with revenue cycle teams and payers to investigate claim denials and appeal decisions when necessary.
• Researches and interprets payer policies, ensuring adherence to reimbursement requirements and claim submission rules.
• Documents account actions accurately and thoroughly in the appropriate systems, maintaining compliance with department protocols.
• Identifies process improvement opportunities, contributing to increased efficiency and streamlined reimbursement workflows.
• Maintains strict confidentiality of patient and financial information, ensuring compliance with HIPAA and corporate policies.
• Performs other duties as assigned.
• Complies with all policies and standards.

• H.S. Diploma or GED required
• Associate Degree or coursework in Accounting, Finance, Healthcare Administration, or related field preferred
• 0-1 years of experience in medical billing, reimbursement, claims processing, or accounts receivable required
• Experience with payer reimbursement policies, claim adjudication, and healthcare revenue cycle operations preferred

• Strong knowledge of medical billing, reimbursement procedures, and payer guidelines.
• Familiarity with claim submission, denial management, and appeals processes.
• Ability to analyze account balances, identify discrepancies, and apply appropriate adjustments.
• Proficiency in electronic health records (EHR), billing software, and reimbursement systems.
• Strong problem-solving and critical-thinking skills, ensuring accurate claims resolution.
• Effective communication and collaboration skills, working with payers, revenue cycle teams, and internal departments.
• Knowledge of HIPAA, compliance regulations, and healthcare reimbursement standards.

011250 CCA-Claims

This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time.

Position Summary:

Reporting to the Director, Claims Operations and Quality Assurance, the Claims Sr. Analyst plays a critical role in ensuring accurate, compliant, and timely reimbursements within the scope of MassHealth and Medicare Advantage programs. Under the direction of the Director of Claims Operations and Quality Assurance, this role is responsible for the end-to-end review, analysis, and resolution of complex reimbursement issues – including underpayments, overpayments, and disputes. The Claims Sr. Analyst serves as a subject matter expert on Medicaid (MassHealth), Medicare, and commercial payment methodologies and supports audit, compliance, and provider engagement initiatives. This role also provides support in managing provider disputes and escalations requiring detailed pricing and reimbursement validation.

Supervision Exercised:

• No, this position does not have direct reports.

Essential Duties & Responsibilities:

• Analyze MassHealth and Medicare claim reimbursements to ensure compliance with contractual terms, state and federal regulations, and internal payment policies.

• Resolve provider inquiries and disputes related to pricing discrepancies, contract interpretation, and fee schedule issues.

• Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances, and Configuration teams to validate and resolve reimbursement concerns.

• Conduct retrospective audits to identify systemic payment issues and recommend resolution pathways.

• Interpret and apply MassHealth fee schedules, All-Payer Rate Setting regulations, and CMS payment methodologies (e.g., DRG, APC, RBRVS).

• Support provider appeal reviews and internal payment integrity investigations by providing reimbursement validation.

• Escalate systemic or high-impact discrepancies to the Director of Claims Operations and Quality Assurance for further investigation or configuration updates.

• Document all research, findings, and outcomes in claims systems (e.g., Salesforce, Facets) in compliance with audit standards and MassHealth requirements.

• Maintain awareness of MassHealth transmittals, billing guides, and program updates to ensure adherence in payment practices.

• Ensure SLA compliance for inquiry resolution, appeal response times, and post-payment audits.

• Assist in the resolution of complex provider disputes and escalations, including direct support to leadership in pricing determinations and dispute case documentation.

Working Conditions:

• Standard office conditions.

Required Education (must have):

• N/A

Desired Education (nice to have):

• Associate’s or Bachelor’s degree in Health Administration, Finance, or related field preferred.

• Certified Professional Coder (CPC) – AAPC

• Certified Claims Professional (CCP)

• Other AHIMA or Medicaid billing-related certifications

Required Experience (must have):

• 3+ years in healthcare claims processing, provider reimbursement, or payment integrity.

• Experience with core claims platforms such as Facets, QNXT, or Amisys.

Desired Experience (nice to have):

• Prior experience working with MassHealth and Medicare Advantage reimbursement rules is strongly preferred.

Required Knowledge, Skills & Abilities (must have):

• Proficiency with Excel and reporting tools for data analysis.

• Understanding of provider contracts, rate tables, and state-set payment methodologies.

• Strong problem-solving and analytical skills.

• Effective verbal and written communication with both internal stakeholders and providers.

• Meticulous attention to detail and documentation standards.

Required Language (must have):

• English

Desired Knowledge, Skills, Abilities & Language (nice to have):

• Knowledge of Facets, MassHealth, and CMS is a plus.

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

Join to apply for the Medicare/Medicaid Claims Reimbursement Analyst role at Commonwealth Care Alliance . Position Summary: Reporting to the Director, Claims Operations and Quality Assurance, the Claims Sr. Analyst plays a critical role in ensuring accurate, compliant, and timely reimbursements within the scope of MassHealth and Medicare Advantage programs. This role involves the end-to-end review, analysis, and resolution of complex reimbursement issues, including underpayments, overpayments, and disputes. The Claims Sr. Analyst serves as a subject matter expert on Medicaid (MassHealth), Medicare, and commercial payment methodologies, supporting audit, compliance, and provider engagement initiatives. It also involves managing provider disputes and escalations requiring detailed pricing and reimbursement validation. Essential Duties & Responsibilities: Analyze MassHealth and Medicare claim reimbursements for compliance with contractual terms, regulations, and policies. Resolve provider inquiries and disputes related to pricing, contracts, and fee schedules. Collaborate with various teams to validate and resolve reimbursement concerns. Conduct audits to identify systemic payment issues and suggest resolutions. Interpret and apply relevant fee schedules, regulations, and CMS payment methodologies. Support provider appeal reviews and internal investigations. Escalate discrepancies to leadership for further action. Document all research and outcomes in claims systems in compliance with standards. Stay updated on program changes and ensure adherence in payment practices. Ensure timely resolution of inquiries and disputes. Assist in complex dispute resolution and provide documentation support. Qualifications: 3+ years in healthcare claims processing, provider reimbursement, or payment integrity. Experience with claims platforms such as Facets, QNXT, or Amisys. Knowledge of MassHealth and Medicare Advantage reimbursement rules is preferred. Proficiency with Excel and data analysis tools. Strong problem-solving, communication, and attention to detail skills. English language proficiency. Education: Associate’s or Bachelor’s degree in Health Administration, Finance, or related field (preferred). Certifications like CPC or CCP are a plus. Employment Type: Full-time Seniority Level: Mid-Senior level This job is active and accepting applications. #J-18808-Ljbffr

011250 CCA-Claims Job Description Position Summary: Reporting to the Director, Claims Operations and Quality Assurance, the Claims Sr. Analyst plays a critical role in ensuring accurate, compliant, and timely reimbursements within the scope of MassHealth and Medicare Advantage programs. Under the direction of the Director of Claims Operations and Quality Assurance, this role is responsible for the end-to-end review, analysis, and resolution of complex reimbursement issues - including underpayments, overpayments, and disputes. The Claims Sr. Analyst serves as a subject matter expert on Medicaid (MassHealth), Medicare, and commercial payment methodologies and supports audit, compliance, and provider engagement initiatives. This role also provides support in managing provider disputes and escalations requiring detailed pricing and reimbursement validation. Supervision Exercised: No, this position does not have direct reports. Essential Duties & Responsibilities: Analyze MassHealth and Medicare claim reimbursements to ensure compliance with contractual terms, state and federal regulations, and internal payment policies. Resolve provider inquiries and disputes related to pricing discrepancies, contract interpretation, and fee schedule issues. Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances, and Configuration teams to validate and resolve reimbursement concerns. Conduct retrospective audits to identify systemic payment issues and recommend resolution pathways. Interpret and apply MassHealth fee schedules, All-Payer Rate Setting regulations, and CMS payment methodologies (e.g., DRG, APC, RBRVS). Support provider appeal reviews and internal payment integrity investigations by providing reimbursement validation. Escalate systemic or high-impact discrepancies to the Director of Claims Operations and Quality Assurance for further investigation or configuration updates. Document all research, findings, and outcomes in claims systems (e.g., Salesforce, Facets) in compliance with audit standards and MassHealth requirements. Maintain awareness of MassHealth transmittals, billing guides, and program updates to ensure adherence in payment practices. Ensure SLA compliance for inquiry resolution, appeal response times, and post-payment audits. Assist in the resolution of complex provider disputes and escalations, including direct support to leadership in pricing determinations and dispute case documentation. Working Conditions: Standard office conditions. Required Education (must have): N/A Desired Education (nice to have): Associate's or Bachelor's degree in Health Administration, Finance, or related field preferred. Certified Professional Coder (CPC) - AAPC Certified Claims Professional (CCP) Other AHIMA or Medicaid billing-related certifications Required Experience (must have): 3+ years in healthcare claims processing, provider reimbursement, or payment integrity. Experience with core claims platforms such as Facets, QNXT, or Amisys. Desired Experience (nice to have): Prior experience working with MassHealth and Medicare Advantage reimbursement rules is strongly preferred. Required Knowledge, Skills & Abilities (must have): Proficiency with Excel and reporting tools for data analysis. Understanding of provider contracts, rate tables, and state-set payment methodologies. Strong problem-solving and analytical skills. Effective verbal and written communication with both internal stakeholders and providers. Meticulous attention to detail and documentation standards. Required Language (must have): English Desired Knowledge, Skills, Abilities & Language (nice to have): Knowledge of Facets, MassHealth, and CMS is a plus. #J-18808-Ljbffr

Job Type Full-timeDescriptionJoin our exciting Billing Team! If you are looking for some challenges, career growth, step up in your billing knowledge this is the right opportunity for you!We are looking for detailed, energetic, focused medical billers who are high achievers and take their career seriously.Job Opening Opportunities:Charge Entry/AR Follow up Specialists openings are available in the following specialties: Imaging, Thoracic, General Surgery, Colorectal, Podiatry, Pain Management, Orthopedics, Radiation Oncology and Call Center.Previous medical billing experience or experience with EPIC/ECW/Athena software is a plus About Us:BASS Medical Group is a large physician owned, physician directed, and patient centered organization. Our goals are to provide high quality, cost effective, integrated, healthcare and physician services. To preserve community based independent physician practice locations throughout California. At BASS Medical Group, our practices are closer and more connected to the people and neighborhoods we serve. With a more personal touch to healthcare and easier access to the care you need, we help guide patients to the best possible outcome.RequirementsRecommend knowledge and skills :Superior phone communication skills with providers, carriers, patients, and employeesExceptional written and verbal communication skillsStrong attention to detailAbility to work in a fast-paced, high-volume work environmentPositive attitudeGreat attendance and punctualityKnowledge of modifiers, insurance plans, and follow up techniquesJob Duties but are not limited to:Perform the day-to-day billing and follow-up activities within the revenue operationsWork all aging claims from Work Ques or Aging reportsPresent trends or issues to supervisor, and work together to make improvementsResolve denials or correspondences from patients and insurance carriersAssist in patient calls and questionsFollow team and company policiesMeet productivity standardsWrite clear and concise appeal lettersMinimum qualifications:High School diploma or equivalentMedical Billing Certificate preferred orAt least a year of Medical billing experienceProficiency with Microsoft office applicationsBasic typing skillsLocation: Walnut Creek, CA or Brentwood, CA (Depending on Experience)Salary: based on experiencePay Scale/Ranges:$21.00 - $2.00/hour*Employees actual pay rate will depend on a host of factors including, without limitation, job location, specialty, skillset, education, and experience. The pay scale/ranges shown are representative of the pay rates for the job title reflected above, but an employees actual pay rate will be determined on a case-by-case basis.Benefits: Medical, Dental, Vision, LTD, Life, AD&D, Aflac insurances, Nationwide Pet Insurance, FSA/HSA plans, Competitive 401K retirement plan. Vacation & Sick Leave, 13 Paid Holidays per yearJob Type: Full-timeSalary Description 16.50- 32.00/hour

POSITION SUMMARY/RESPONSIBILITIES    

Identifies and enrolls indigent and under-insured patients into drug assistance reimbursement programs which provide drug replacement and reimbursement compensation.  Monitors contain eligibility status and document drug shipments received through a computerized tracking system.  Serves as a resource in facilitating resolution of insurance denial referrals.  Communicates effectively with pharmacy, hospital administration, medical staff, patients and personnel in the patient assistance programs using verbal and written interpersonal communication skills.  Requires the ability to work independently and coordinate assigned projects efficiently.  Effectively utilizes problem-solving ability, significant interpersonal contact and concentration abilities, analytical skills and in-depth knowledge of computer software. Coordinates all information regarding patients enrolled in assistance programs for drug therapies using various computer software programs. Creates, expands and maintains computerized databases to support patient enrollment in assistance programs and tracks case-specific assistance provided in response to reimbursement denials.  Conducts patient interviews and conveys reimbursement denial potential to patients and medical staff. Reviews all outpatient 3rd party rejections and assists the patient in resolving the problem.  Coordinates 3rd party billing, problems with eligibility, rejections, etc. with the Outpatient Pharmacy Supervisor and the Pharmacy Billing Section.

EDUCATION/EXPERIENCE    

Texas State Board of Pharmacy registration required.  National Certification as a Certified Pharmacy Technician (CPhT) is recommended.    Three (3) years' experience in a medical or pharmacology-related field to include project coordination; database/spreadsheet development and management; and/or application programming; processing and overseeing medical insurance billing and reimbursement cost capture is preferred. Must have demonstrated independent judgment

The Director of Reimbursement is responsible for ensuring that the charge description master (CDM) file is compliant with Infirmary Health policy, appropriately reflects clinical practice and is aligned with reporting requirements for government and major commercial third-party payers, as well as directing the overall hospital reimbursement function across IH, to provide third party reimbursement administration in compliance with IH standards of quality, efficiency, and desired outcomes.

Baccalaureate degree

Accounting/Finance Major

5 of the most recent 7 years' experience working directly with hospital reimbursement in a leadership role

MBA

Additional knowledge of home health, DME, physician and SNF reimbursement

CPA, CMA, FHFMA