Medical Reimbursement Specialist

Job Description

This position is responsible for effective follow up on accounts / invoices for assigned Payors resulting in payment or final adjustment.

Proficiency in assigned Payors billing and payment guidelines is required, to ensure the departmental collection goals are met or exceeded as


* Work accounts / invoices until all charges are paid or denied by the insurance carrier.


* Process insurance / patient correspondence, deductibles, medical records request, non-covered services, adjustments and appeals.


* Process request for adjustments, account type changes, guarantor merges, and transfers when necessary, according to enterprise guidelines.


* Accurately enter patient demographics, guarantor, and coverage information into Epic system.


* Accurately perform retro adjudication, change filing order, request necessary adjustments / reversal of adjustments, or refile claims.


* Distribute payments for assigned financial class to ensure payments are posted to correct service dates and request changes if needed.


* Identify and report payor trends and issues in order to effect timely resolution.


* Know and use data entry ground rules, Standard Business Practice, Nemours Intranet, Managed Care Manual and where to locate any hard copy or electronic versions.


* Keep abreast of all insurance and system changes, Payor Plan Standards, Just in Time Learning's, News to Use, etc.


* Demonstrate excellent customer service that promotes patient, staff and customer satisfaction, and reflects the Mission, Vision, and Values of Nemours.

Performance Skills:


* Working knowledge in medical insurance billing guidelines required.


* Experienced in using reference materials: CPT, ICD10, HCPCS, CMS Guidelines, NCCI and Anesthesia reference materials.


* Demonstrate professional conduct with both internal and external customers.


* Ability to recognize and uphold confidentiality requirements expected by the Nemours Foundation.


* Works independently or as a team, takes direction, prioritizes, makes decisions, and accepts feedback with the willingness to accept change.

Job Requirements


* High School Diploma required.


* Billing a plus with use of payor portals.


* Knowledge of EPIC system a plus.


* Knowledge of billing CPT Codes and Dx Codes a plus.

About Us

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year.

We deliver care across six states through two freestanding children's hospitals - Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida - along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.

Backed by the Nemours Foundation and Alfred I.

duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention...