Key Responsibilities and Required Skills for Healthcare Reimbursement Specialist

🎯 Role Definition

The Healthcare Reimbursement Specialist is a revenue-cycle professional responsible for ensuring accurate, timely reimbursement from public and commercial payers. This role focuses on claims submission and follow-up, denial management, payer contract interpretation, and regulatory compliance (Medicare, Medicaid, commercial). The ideal candidate combines deep knowledge of coding and billing (ICD-10, CPT, HCPCS), payer policy, and analytic problem-solving to maximize net revenue while maintaining strong payer and provider relationships.

📈 Career Progression

Typical Career Path

Entry Point From:

Medical Biller / Claims Processor
Revenue Cycle Analyst / Patient Financial Services Representative
Clinical Coder (ICD-10 / CPT) or Eligibility Specialist

Advancement To:

Senior Reimbursement Specialist / Reimbursement Manager
Revenue Cycle Manager or Director of Reimbursement
Payer Contracting Manager or Denials & Appeals Lead

Lateral Moves:

Payer Relations Specialist
Appeals & Audit Analyst
Clinical Documentation Improvement (CDI) Specialist

Core Responsibilities

Primary Functions

Prepare, review and submit clean claims to Medicare, Medicaid and commercial payers using EMR/billing systems (Epic, Cerner, NextGen, Meditech), ensuring coding (ICD‑10, CPT, HCPCS) and documentation support medical necessity for accurate payment.
Monitor claim status end‑to‑end: adjudication, payments, remittance advice (RA/EOB), adjustments and re-bills; escalate stuck or suspended claims to appropriate internal teams or payer contacts.
Conduct comprehensive denial management including root-cause analysis, development and submission of clinical and non-clinical appeals, and tracking of appeal outcomes to reduce future denials and recover underpayments.
Interpret and apply payer policies, fee schedules, coverage criteria, and contractual terms to determine appropriate claim submission pathways and identify instances of underpayment or non-compliance.
Perform regular audits of billed services versus clinical documentation and coding to identify undercoding, overcoding, and documentation gaps; coordinate with providers and coding teams to implement corrective actions.
Review and reconcile Explanation of Benefits (EOBs) and Electronic Remittance Advices (ERAs), post payments and adjustments accurately to patient accounts, and investigate discrepancies between expected and actual payments.
Analyze payer payment patterns and write-offs, prepare recovery action plans, and implement targeted interventions to improve collections and reduce days in accounts receivable (AR).
Build and maintain collaborative relationships with payer representatives to negotiate claim denials, expedite complex appeals, and clarify policy interpretations that affect reimbursement.
Prepare and submit timely prior authorizations, precertifications and utilization reviews as required by payer policies to prevent claim denials and delays in payment.
Research and resolve complex billing issues including bundling/unbundling disputes, duplicate payments, claim rejections, and coordination of benefits; document outcomes and workflow improvements.
Manage high-volume claim re-submissions and corrected claims (COB, corrected UB‑04/837) ensuring appropriate modifiers, diagnosis mapping and provider signatures are present to avoid recurrences.
Execute retrospective and prospective denial trend analyses and present findings and recommendations to revenue cycle leadership and clinical teams to drive process change.
Educate providers, coders and front-office staff on payer-specific documentation requirements, coding updates, and best practices to reduce denials and increase first-pass yield.
Maintain current knowledge of federal and state regulations (Medicare, Medicaid, state plans), payer updates, and industry coding changes; proactively update policies and procedures to maintain compliance.
Coordinate and support external audits, third-party reviews, and payer medical necessity inquiries by compiling documentation, clinical records and claims histories.
Calculate and appeal underpayments by comparing paid amounts to contracted rates and collecting documentation to support reimbursement recovery, including post-pay audits and retrospective reviews.
Support charge capture accuracy by validating clinical documentation and order data, identifying missed charges, and working with clinical and HIM teams to close revenue gaps.
Create and maintain detailed logs of appeals, overpayments, refunds, and recovery efforts; provide monthly performance metrics and KPIs to leadership including denial rates, appeal success rates, and AR aging.
Lead or participate in cross-functional projects to streamline claims workflows, implement new payer interfaces, and improve denial prevention tactics using automation tools and process redesign.
Serve as subject matter expert for complex payer scenarios including ERISA, self-insured plans, workers’ compensation, and secondary payer coordination to ensure correct billing paths.

Secondary Functions

Assist with special projects such as payer onboarding, claims system upgrades, and policy rollouts by providing reimbursement expertise and testing claim scenarios.
Support ad-hoc reporting requests and generate actionable insights using Excel, pivot tables, and basic SQL queries to identify high-impact revenue opportunities.
Work with finance and compliance teams to reconcile recovered funds, refund processing, and accounts write-offs to ensure accurate general ledger entries.
Contribute to continuous improvement initiatives by documenting standard operating procedures (SOPs), training materials, and playbooks for denial handling and appeals workflows.
Participate in regular interdisciplinary meetings (billing, coding, clinical leadership, IT) to address systemic issues and drive measurable reductions in denials and AR days.
Maintain a knowledge base of payer contacts, escalation paths and key policy documents to accelerate claim resolution and support colleagues across the revenue cycle.

Required Skills & Competencies

Hard Skills (Technical)

Deep knowledge of medical coding systems: ICD‑10‑CM, CPT, HCPCS and modifiers.
Hands-on experience with billing and EHR platforms such as Epic (Resolute/Cadence), Cerner, Meditech, NextGen, Athenahealth or similar.
Proficiency with claims formats and transactions: CMS‑1500, UB‑04, ANSI X12 837/835/276/277 and ERA reconciliation.
Strong understanding of payer rules, Medicare/Medicaid regulations, managed care plans, and commercial insurance policy interpretation.
Denials management and appeals expertise, including drafting clinical appeal letters and managing multi-level appeals and external reviews.
Experience with payer contract interpretation, fee schedule analysis, and identifying underpayment opportunities.
Advanced Excel skills (VLOOKUP, INDEX/MATCH, pivot tables) and ability to produce clear analytics and KPI dashboards.
Familiarity with claim scrubbers, clearinghouses, and Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA) processing.
Knowledge of audit processes, refund recovery, overpayment remediation, and compliance requirements (HIPAA, False Claims Act awareness).
Basic SQL or data query experience and experience working with revenue cycle reporting tools (e.g., QGenda, Tableau, Power BI) is a plus.
Experience with prior authorization workflows and utilization management tools.

Soft Skills

Exceptional analytical and problem-solving ability with attention to detail and accuracy under pressure.
Effective written and verbal communication skills tailored to clinicians, payers, and executive stakeholders.
Strong organizational and time-management skills with the ability to prioritize high-volume tasks and manage multiple appeals simultaneously.
Negotiation and persuasion skills for effective payer communications and dispute resolution.
Customer-service orientation and empathy when addressing provider and patient billing concerns.
Collaborative team player who can influence cross-functional partners and drive process changes.
Adaptability to evolving payer rules, regulatory changes, and system upgrades.
Initiative and ownership mindset with the ability to identify and implement continuous improvement opportunities.

Education & Experience

Educational Background

Minimum Education:

Associate degree in Health Information Management, Healthcare Administration, Accounting, or related field. Equivalent healthcare revenue cycle experience may substitute.

Preferred Education:

Bachelor’s degree in Healthcare Administration, Business, Finance, Health Information Management or related field.
Certifications such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional in Healthcare Quality (CPHQ) or Certified Revenue Cycle Representative (CRCR) are a plus.

Relevant Fields of Study:

Health Information Management
Healthcare Administration
Business / Finance
Health Policy / Public Health

Experience Requirements

Typical Experience Range: 2–5 years of progressive experience in medical billing, claims adjudication, denials management or revenue cycle operations; may vary by employer.

Preferred:

3+ years working directly with payer denials, appeals, and reimbursement analytics.
Demonstrated experience with Medicare fee-for-service and Medicaid billing, plus at least one major EHR/billing system (Epic, Cerner, Meditech).
Track record of reducing denial rates, improving first-pass clean claim rates, or recovering significant underpayments.