Specialty Medication Reimbursement Specialist

CLS; Webster (TX); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

401(k) matching

Dental Insurance

Disability insurance

Health insurance

Life insurance

Paid time off

Job summary

CLS Health, a Houston-based multispecialty provider, seeks a Revenue Cycle Specialist to audit infusion and specialty medication claims, identify root causes of denials, and work with payers and internal teams to maximize reimbursements.

Responsibilities include monitoring pay-to-submit cycles, auditing reimbursements, and coordinating corrections with billing and intake. Experience in infusion claims and payer portals is preferred, CPC or similar certification is a plus.

Qualifications

• 3+ years in medical billing, reimbursement, or revenue cycle with infusion or specialty drug claims experience
• Able to read payer policies, fee schedules, and EOBs and explain denials clearly
• Experience with copay assistance and manufacturer reimbursement reconciliation

Responsibilities

• Monitor unbilled and unpaid infusion and specialty encounters to keep claims moving for timely submission
• Audit paid claims against expected reimbursement using payer fee schedules and drug allowables
• Work denials and underpayments and identify root causes: authorization, benefits, site-of-care, or coding errors
• Call payers to confirm coverage, fee schedule, and buy-and-bill vs specialty requirements for meds
• Reconcile copay card and foundation assistance payments and follow up on manufacturer reimbursements
• Coordinate corrections and rebills with billing and intake, feeding findings back to prevent recurring denials
• Report payer and drug-level profitability and denial trends to Ancillary Services Manager

Skills

Medical billing

Denials management

Excel

Payer policies

Reading EOBs

Education

CPC certification

Medical billing certification

Tools

Excel

Power BI

Payer portals

Job description

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