Reimbursement Specialist - Pharmacy RCM Collections

  • 3200 Lake Emma Rd, Lake Mary, FL 32746, USA
  • Full-time

Company Description

Kroger Specialty Pharmacy is a Clinical Pharmacy. Our programs optimize patient outcomes by blending a high-touch, caring patient experience with specialized clinical knowledge, personalized care programs, and administrative expertise.

Job Description

Position Summary:
Perform duties to process medical billing and PBM and medical collections with focus on accuracy, timeliness and adherence to process, to reduce denial rate, DSO, and bad debt. To recognize additional revenue opportunities, and improve in collection rates, while working within the limits of standard or accepted practice.

Essential Functions:
• Review patient files for completeness and accuracy, identify and audit claims, ensure all revenue opportunities are included, and complete and submit billing, primary and secondary, to payers for reimbursement, via paper bills and clearing house submittals.
• Review documents received including Explanations of Benefits (EOBs), Remittance Advices (RAs) and other documents indicating denials or claims acceptance. Identify reasons for denials, take required corrective action, and take ownership of claims through to timely, successful collection.
• Analyze denials, identify trends and recommend process improvement opportunities that will result in DSO reduction, superior collection rate and intervals, reduced bad debt, and simplified processes that are responsive to the requirements of specific payers.
• Review claims with outstanding balances and identify actions to successfully collect revenues. Follow up with insurers and patients to collect outstanding balances in an environment of world-class customer service focused on building enduring customer and business relationships.
• Document case activity, communications and correspondence in computer system to ensure completeness and accuracy of account activity and actions taken to resolve outstanding claims issues. Schedule follow-ups in required intervals.
• Utilize Payer Portals via the internet for claim disposition.
• Contribute medical billing expertise to the design of training and knowledge transfer programs, materials, policies and procedures to improve the efficiency and effectiveness of the Revenue Cycle Management team.
• Assist with the processing on online adjudication of collection issues and nurse billing as assigned.
• Perform or assist with any operations, as required to maintain workflow and to meet schedules and quality requirements.
• Participate in any variety of meetings and work groups to integrate activities, communicate issues, obtain approvals, resolve problems and maintain specified level of knowledge pertaining to new developments, requirements, and policies.
• Perform other related duties as assigned.


• Superior communications skills; listening, speaking, understanding, and writing English while influencing patients, care givers, payer representatives and others, answering questions and advancing reimbursement and collection efforts.
• Proven understanding of processes, systems and techniques to ensure successful billing and collection working with all payer types.
• Proven ability to identify gaps and problems from review of documentation, determine lasting solutions, make effective decisions, and take necessary corrective action.

Education/Experience Requirements:
• High School Diploma or equivalent and additional specialized training in medical billing and / or collections.
• Minimum 2 years of medical billing and/or collections experience.
• Coding Course Certification is highly preferred.

Additional Information

All your information will be kept confidential according to EEO guidelines.