Catholic Health Initiatives Reimbursement Specialist - Payer Contracting Compliance - Mercy Health Network in DES MOINES, Iowa

Reimbursement Specialist - Payer Contracting Compliance - Mercy Health Network


Job Summary / Purpose

The Reimbursement Specialist is responsible for maintaining, researching and resolving reimbursement issues related to contracts between MHN providers and managed care payers or third party payers. Supports the enforcement of payer contracting terms associated to payment performance of such payers.

Essential Key Job Responsibilities

  1. Researches and resolves reimbursement variances between payments received and expected allowances to ensure payments are within contract guidelines.

  2. Requests additional payment from payer when necessary.

  3. Researches payer specific policies to determine coding/claims submission requirements and associated reimbursement

  4. Monitors payer specific changes in claims submission requirements and provides routine updates to MBO and RCM Vendor

  5. Acts as a contracting compliance liaison between MBO and RCM vendor to coordinate and escalate payer related issues

  6. Collects and summarizes reports for leadership including contract terms and monthly accomplishments including post pay audit findings, and additional reimbursement as a result of escalation efforts

  7. Maintains the ability to understand and utilize a complex and highly sophisticated billing system

Non-essential Job Responsibilities

  1. Other duties as assigned by management


Minimum Qualifications

Required Education for CHI Leadership Job Levels

(from Supervisor through President)

Required Education for Staff Job Levels


Required Licensure and Certifications


Required Minimum Experience

  • 6 mos. – 2yrs hospital/clinic business office experience required.

  • Minimum of three (3) years hospital or physician/professional billing or business office experience required if no specialized medical office training.

  • Background in financial healthcare reimbursement analysis is required, including an understanding of diagnosis and procedure coding, billing practices, and payment methodologies. Managed care knowledge preferred.

  • Prior experience in working with insurance payer reimbursement policies and/or contracts preferred

Required Minimum Knowledge, Skills and Abilities

Knowledge of:

  • Health care systems and inter/intra-relationships;

  • Hospital finance, revenue cycle, and information systems;

  • Complex managed care concepts and processes;

  • Health insurance pricing and associated benefit designs

  • Provider billing and claims processing

Skills in:

  • Strong skills in statistical analysis

  • Strong microcomputers (including spreadsheet, database, and word processing software);

  • Strong written and verbal communication;

  • Management and interpretation of data;

Ability to:

  • Analyze and problem solve;

  • Coordinate to engage people and technology and lead projects from beginning to end;

  • Read an interpret contract language and reimbursement mechanisms;

  • Develop positive working relationships with senior management, physicians, hospital staff, and managed care company representatives;

  • Communicate effectively with all levels of staff and customers;

  • Demonstrate high level of self-directed motivation; professionalism; and trust;

  • Handle multiple tasks on a daily basis.

PREFERRED Education and/or Experience

High School graduate plus medical office training education required

Two year degree in business or related healthcare field preferred

Job Professional Non-Clinical


Daily Schedule Days

Scheduled Hours per 2-week Pay Period 80

Weekends Required None

Req ID: 2018-R0162615

We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.