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Reimbursement Specialist - Managed Care

Administrative / Business Support
Adventist Health System Corporate Office

If you want to be a part of a place that provides nothing less than extraordinary compassionate care, then Adventist Health System is the place for you!

We are currently seeking qualified candidates for a Reimbursement Specialist position that will be based in our Managed Care department. This position is based at our corporate office in Maitland, FL.


This position is responsible for analyzing payer account reconciliation discrepancies and identifying variance causes for the AHS facilities for the identification of underpayments and denials. Responsible and engaged in recognizing payer trends to maximize expected reimbursement for the managed care contracts. Analyze billing and coding discrepancies. Maintains strong working relationships with PFS and other departments and provides direction to AHS facilities to promote consistent operations. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.


· Utilizes skill and knowledge of multiple regional databases such as Series, PCON, Cerner Patient Accounting (CPA), CCM, OPTUM, Radiant and WebNow.

· Utilizes Mediregs, CMS and state specific Medicaid pricing tools to calculate payment discrepancies and determine correct payer reimbursement and contractual adjustments.

· Identifies system loading discrepancies within PCON and/or CCM and refers to Senior Reimbursement Specialist, Contract Manager or Contract Administrator for correction.

· Identifies Series and/or CPA system malfunctions and provides documentation to Senior Reimbursement Specialist or Manager as needed for investigation.

· Works within Series and/or CPA, utilizing available departmental tools, to properly identify denied claims and claims not paid in accordance with the negotiated contract terms for Adventist Health System. Documents system, assigns appropriate denial/action codes following departmental procedures and refers to PFS Department with instruction for proper reconciliation of account.

· Verifies, edits or instructs PFS Department to update payer demographic information in system as needed for proper reconciliation and collection.

· Effectively communicates with Senior Reimbursement Specialist, Contract Managers or Contract Administrators on system calculation issues.

· Effectively participates in meetings and discussions with Managed Care Director(s), Operations Manager, Senior Reimbursement Specialist and other staff as necessary to effectively discuss system and/or payer issues in regards to the reconciliation of managed care patient accounts.

· Effectively provides direction to regional PFS Departments in regards to payment discrepancies by properly documenting system accounts for payment resolution.

· Supports regional AHS PFS and Managed Care Departments, co-workers and leadership in the goal of securing appropriate reimbursement through managed care patient account review.

· Demonstrates an eagerness to assist co-workers in the completion of tasks as needed.

· Performs special projects and tasks as requested by senior staff and leadership.

· Demonstrates and encourages a team environment by displaying an eagerness to work together to reach a common goal.

· Supports the overall mission of Adventist Health System and the role of the Managed Care Department in that mission.

· Provides an intricate level of expertise relating to payer reimbursement based on state statues and federal law.

· Responsible for understanding and interpreting multiple payment methodologies for payer types such as Commercial Managed Care, Managed Medicare, Managed Medicaid and other governmental payers for regional AHS facilities.

· When requested provides data to Operations Management to assist regional AHS PFS Directors, Managed Care Directors and Registration Administration in identifying operational issues.

· Trends payer performance by identifying loading inaccuracies at the payer level.

· Responsible for maintaining thorough knowledge of payer financial contract terms and conditions.

· Maintains an intricate level of knowledge regarding Medicare Regulatory updates/changes published by CMS to maximize reimbursement.

· Displays a willingness to grow and develop skills required to perform his/her job duties.

· Takes the initiative to seek out education and training in the field of Managed Care, Managed Medicare, Managed Medicaid, Auto, Tricare, Work Comp and the objectives of the department.

· Facilitates in the education and training of PFS staff at the AHS regional facilities as needed.

· Contributes to the maintenance of training materials to incorporate best practices throughout the team.

· Completes assigned tasks in the appropriate time period.

· In group situations, effectively contributes to the overall completion of work product according to the applicable directive and deadline.

· Maintains an acceptable work pace to meet established standard goal.

· Readily able to adapt to new situations and changing priorities in order to accomplish department goals.

· Does not interfere with the ability of co-workers to complete their duties.

· Adheres to applicable internal policies, procedures, and guidelines set forth by Adventist Health Systems, its associated hospitals, physician groups, PHOs, and ancillaries during the execution of assigned duties.

· Abides by all applicable rules, regulations, and laws prescribed by any authoritative governing body such as applicable State Laws, AHCA, etc.

· Deals with patient information in a sensitive manner to ensure respect and privacy for patient and expeditious handling of related issues.

· Clearly and successfully represents self and this organization in a professional, courteous manner.


· Typing skills

· Microsoft Outlook

· Standard Office Equipment

· Ability to think analytically

· Able to conduct research

· Detail oriented

· Microsoft Office Applications (Pref erred)

· Software (Preferred) :

· Series


· Cerner Patient Accounting

· Cerner Contract Management

· CMS Calculator

· Perceptive Content

· Payer Websites

· MediRegs

· Radiant


· High school diploma or equivalent

· Minimum of two years’ experience in the healthcare industry

· Bachelor’s degree in related field, i.e. business, healthcare, marketing (Pref erred)

· Experience in managed care, patient financial services, or provider relations (Pref erred)

If this position sounds like a great match for your skills set and experience, please apply online now!

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