Specialty Medication Reimbursement Specialist

CLS Health; Webster (TX); Sur place; USD 50 000 - 70 000; Plein temps

Avantages offerts par ce poste

401(k) matching

Dental Insurance

Disability insurance

Health insurance

Life insurance

Paid time off

Résumé du poste

CLS Health is seeking a skilled medical billing professional to audit infusion and specialty drug claims, identify root causes of denials, and collaborate with payers and internal billing teams to recover revenue. You will work with payer portals, review fee schedules, and ensure timely submissions of claims.

The role focuses on reducing denials, reconciling copay assistance and manufacturer reimbursements, and communicating findings to improve intake processes.

Qualifications

• 3+ years in medical billing, reimbursement, or revenue cycle with infusion or specialty drug claims.
• Working knowledge of J-codes, NDC and unit billing, buy and bill, specialty pharmacy, and medical vs pharmacy benefit.
• Able to read payer policies, fee schedules, and EOBs and explain a denial in plain terms.
• Experience with copay assistance and manufacturer reimbursement reconciliation.
• Comfortable with Excel and payer portals; Power BI or reporting experience is a plus.
• Coding certification (CPC or similar) is a plus.

Responsabilités

• Monitor unbilled and unpaid infusion and specialty encounters and keep claims moving to timely submission.
• Audit paid claims against expected reimbursement using payer fee schedules and drug allowables (ASP, WAC, contracted rates).
• Work denials and underpayments and identify the cause: authorization, benefits or site-of-care restriction, coding or NDC errors, documentation gaps, or copay assistance that was never reimbursed.
• Call payers to confirm coverage, fee schedule, and buy and bill vs specialty pharmacy requirements for specific medications.
• Reconcile copay card and foundation assistance payments and follow up on outstanding manufacturer reimbursements.
• Coordinate corrections and rebills with billing and the intake team, and feed findings back into the intake process so the same denial doesn't recur.
• Report payer and drug-level profitability and denial trends to the Ancillary Services Manager

Connaissances

Medical billing

Revenue cycle

J-codes/NDC

Outils

Excel

Power BI

Description du poste

About CLS Health

CLS Health is a growing healthcare system in Houston, Texas that is taking a different approach to healthcare. We are a physician-led healthcare group that focuses on providing patients with holistic, multispecialty care. We're a dynamic team on a mission to provide better healthcare options for Houstonians!

Description

About CLS Health

CLS Health is a growing healthcare system in Houston, Texas that is taking a different approach to healthcare. We are a physician-led healthcare group that focuses on providing patients with holistic, multispecialty care. We're a dynamic team on a mission to provide better healthcare options for Houstonians!

Position Summary

Audits infusion and specialty medication claims to find out what got paid, what didn't, and why, then fixes the root cause. This role works payers, manufacturer programs, and internal billing to recover revenue and prevent repeat denials.

Responsibilities

• Monitor unbilled and unpaid infusion and specialty medication encounters and keep claims moving to timely submission
• Audit paid claims against expected reimbursement using payer fee schedules and drug allowables (ASP, WAC, contracted rates)
• Work denials and underpayments and identify the cause: authorization, benefits or site-of-care restriction, coding or NDC/unit errors, documentation gaps, or copay assistance that was never reimbursed
• Call payers to confirm coverage, fee schedule, and buy and bill vs specialty pharmacy requirements for specific medications
• Reconcile copay card and foundation assistance payments and follow up on outstanding manufacturer reimbursements
• Coordinate corrections and rebills with billing and the intake team, and feed findings back into the intake process so the same denial doesn't recur
• Report payer and drug-level profitability and denial trends to the Ancillary Services Manager

Benefits

• 401(k) matching
• Dental Insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off

Requirements

• 3+ years in medical billing, reimbursement, or revenue cycle with direct experience in infusion or specialty drug claims
• Working knowledge of J-codes, NDC and unit billing, buy and bill, specialty pharmacy, and medical vs pharmacy benefit
• Able to read payer policies, fee schedules, and EOBs and explain a denial in plain terms
• Experience with copay assistance and manufacturer reimbursement reconciliation
• Comfortable with Excel and payer portals; Power BI or reporting experience is a plus
• Coding certification (CPC or similar) is a plus