Payer Reimbursement Rep

Managed Care & Payer Relations  
Full Time
AM Shift 

Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #2 in the state and #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of the Best Places to Work in South Carolina.

The 607-bed teaching hospital anchors a health care network that includes five community medical centers and employs more than 8,000 health care professionals. The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina’s first HeartCARE CenterTM and an accredited Cancer Center of Excellence affiliated with MUSC Hollings Cancer Center for research and education. The network also features an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer’s care center and nearly 80 physician practices.  Its postgraduate medical education programs include family medicine and transitional year.





Job Summary

To research identified "short pays/underpayments" by insurance payers and to aggressively pursue and overturn identified underpayments from these payers with timeliness and accuracy. Analyze and interpret complex managed care contracts, provider requirements and payment methodologies for hospital-based and/or physician-based reimbursement. Negotiate and insist accountability with third party payers on accounts through follow-up with accuracy and timeliness. Utilize all available resources (on-line web-sites, contract management software, etc.) to aid in the expedient recovery of underpaid funds.

Minimum Qualifications

Minimum Education: High School Diploma or Equivalent
Minimum Years of Experience: 4 years of experience in healthcare finance or managed care environment
Substitutable Education & Experience: 4 years of experience can be substituted for the following:
Associate's Degree with 2 years of experience in healthcare finance/managed care environment;
Bachelor's Degree with 1 year of experience in healthcare finance/managed care environment
Required Certifications/Licensure: None.
Required Training: Ability to manipulate data in spreadsheets (i.e. Microsoft Excel) in order to report trends and statuses to supervisor;  Working knowledge of managed care terminology, managed care reimbursement methodologies (i.e. DRG, per diem, fee schedule, APC) and billing/coding terminology (ICD-9, CPT, Revenue Codes);  Procedural knowledge of accounts receivable management and basic understanding of revenue cycle.

Essential Functions

  • Analyze and interpret complex managed care contracts, provider requirements and payment methodologies for either hospital-based reimbursement or physician-based reimbursement based on payers assigned.
  • Interpret remits/EOBs as well as payer guidelines, payment policies, ICD 10-coding and NCCI edits to determine claim payment accuracy.
  • Validate registration of patient accounts and posting accuracy according to EOB in verifying underpayment.
  • Investigate, pursue and overturn with accuracy and timeliness underpaid accounts by insurance payers. Thoroughness and reliability are essential because of the detailed nature of the work and for credibility with insurance payers.

Duties & Responsibilities

  • Aggressively overturn erroneous underpayments while maintaining a high level of professionalism. This may include discussing account issues via phone calls to provider services, logging inquiries to payer’s website, sending emails to dedicated payer representative, discussing issues during monthly payer calls, etc.
  • Document accurately and timely in billing application and contract management software.
  • Trend and report underpayment issues to supervisor as they arise.
  • Performs all other duties as assigned by supervisor.

We are committed to offering quality, cost-effective benefits choices for our employees and their families:

  • Day ONE medical, dental and life insurance benefits 
  • Health care and dependent care flexible spending accounts (FSAs)
  • Employees are eligible for enrollment into the 403(b) match plan day one.  LHI matches dollar for dollar up to 6%.
  • Employer paid life insurance – equal to 1x salary
  • Employee may elect supplemental life insurance with low cost premiums up to 3x salary 
  • Adoption assistance
  • LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
  • Tuition reimbursement
  • Student loan forgiveness

Equal Opportunity Employer
It is the policy of LMC to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. LMC strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. LMC endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.

Nearest Major Market: Columbia
Nearest Secondary Market: South Carolina