Reimbursement Specialist
19 hours ago
San Francisco
Job Description Element Science, Inc. is a medical device and digital health company focused on developing solutions at the intersection of clinical-grade wearables, machine learning algorithms, and lifesaving therapies in order to address leading causes of death and hospitalization in patients with heart disease, primarily as they transition from the hospital-to-home. By putting the needs of patients and physicians first, our personalized digital devices, which are designed for function, comfort, and ease-of-use, aim to redefine the paradigm of care for these patients. Our first product, a wearable patch defibrillator, is initially targeted at treating the more than 500,000 patients in the US with an elevated temporary risk of potentially experiencing a lethal heart rhythm. Headquartered in San Francisco, our funders include Third Rock Ventures, Google Ventures, Deerfield Healthcare, Qiming Venture Partners USA, Cormorant Asset Management, and Invus Opportunities. SUMMARY OF ROLE: As a Reimbursement Specialist, you play a vital role in ensuring patients have access to the care they need while supporting the financial health of the organization. You'll be at the forefront of the order-to-cash process, verifying insurance coverage, assessing medical necessity, and securing prior authorizations with accuracy and efficiency. This role is ideal for someone who thrives in a fast-paced, mission-driven environment and takes pride in removing barriers to care while enabling timely order fulfillment and reimbursement. RESPONSIBILITIES: • Gather all necessary documentation, as it relates to payer requirements, standard operating procedures, and compliance programs to be able to bill the insurance payer on record, • Thoroughly review submitted clinical documentation and compare to payers' medical policy to determine if the service will be covered, • Provide clear and detailed communicate to Field team and/or providers if additional information is required to have a valid order or to ensure insurance coverage, • Utilize web portals and/or phone to verify patients' insurance including eligibility, benefits (coinsurance, deductible, max out of pocket) and calculate patients estimated out of pocket, • Confirm prior authorization requirements and submit via web portal, fax or phone as applicable, • Draft single case agreements for out of network payers to secure in network benefits for patients, • Handle both inbound and outbound phone calls from/to patients with questions regarding their out-of-pocket costs and/or financial assistance qualifications, • Complete billing checklist to ensure first pass claims submissions, • Maintain accurate and detailed notes as it pertains to all aspects of the Reimbursement processes within NikoHealth, • Monthly update of patients' benefits, demographic and insurance information as needed, • Confirm new prescribers' qualifications to order including NPI, PECOS enrollment and OIG status and add to billing and clinical systems, • Maintain a strong knowledge of guidelines related to HIPAA, OIG Compliance, medical coding, and billing/reimbursement, • Assist Sales and other departments to resolve billing issues, • Provide exceptional customer service to patients and providers through friendly, caring, informative, and professional interactions, • 3-5 years prior experience in a Reimbursement role in healthcare, medical device or DME responsible for benefits, eligibility and prior authorizations, • Associate's degree or equivalent professional experience, • Minimum of 1 year calculating and communicating financial estimates to patients, • Knowledgeable medical terminology including HCPCS and ICD-10 coding, • Possession of one or more prestigious certifications such as Certified Professional Coder (CPC), Certified Professional Coder Hospital (CPCH), Certified Coding Specialist (CCS), or Certified Outpatient Coder (COC) a plus, • Demonstrated excellence in customer service delivery, • Exceptional capacity for follow-through, organization, and meticulous attention to detail. Element Science offers a very competitive salary and benefits package including, but not limited to: • Stock Options, • 90% employer-paid medical, dental, and vision insurance, • Company-paid Basic Life Insurance, • 401(k) retirement plan (Traditional and Roth), • Competitive Paid Time Off, • Paid Holidays, • FSA (Flexible Spending Accounts), • HSA (Health Savings Account)