Job Description
Job Summary:
The Refund Specialist is responsible for researching patient accounts across all refund types to determine whether payments have been correctly applied and if a refund is warranted. This role involves detailed review of insurance payments, explanation of benefits (EOBs), and account activity to ensure accurate resolution of credit balances while maintaining compliance with payer guidelines, regulatory requirements, and internal policies. The Refund Specialist works collaboratively across departments to identify trends, recover funds that may otherwise be refunded incorrectly, and support overall revenue integrity.
Key Responsibilities:
Review and analyze patient account activity to determine appropriate refund actions.
Review explanation of benefits (EOBs) related to refund requests, overpayments, recoupments, and forward balances.
Apply patient payment transfers, charge corrections, contractual adjustments, and refunds accurately.
Work all payments daily and ensure monies are applied correctly.
Resolve credit balances through refunds, adjustments, transfers, or other appropriate actions.
Contact insurance payers to obtain additional information regarding coordination of benefits, contractual adjustments, and patient responsibility.
Apply federal and state prompt payment regulations to validate or invalidate insurance refund requests when applicable.
Identify payment variances, underpayments, recovery opportunities and communicate findings to leadership.
Identify payer trends or workflow issues contributing to credit balances and notify management.
Ensure all validated government payer refund requests are processed within required payer guidelines.
Maintain daily, weekly, and monthly quantitative and qualitative production standards.
Coordinate work assignments with peers to ensure timely completion of departmental responsibilities.
Communicate effectively with Business Office staff, leadership, and affiliated departments to fulfill information requests.
Respond to emails from Business Office, leadership, and assigned cases within 48 hours.
Perform all duties in compliance with Medicare, federal, state, contractual agreements, and OSM internal policies.
Maintain strict confidentiality of PHI and always comply with HIPAA regulations.
All other duties as assigned
Education and Experience:- High School Diploma or equivalent required; college coursework or degree preferred.
- Minimum of 3–5 years of experience in medical reimbursement, healthcare insurance collections, patient accounting, medical collections, or a similar role within a medical or physician practice.
- Minimum of 3–5 years of experience resolving credit balances, performing account reconciliation, processing refunds, identifying variances, and analyzing payment trends.
- Strong experience collecting payments from insurance carriers required.
- Experience as a payment poster preferred but not required.
- Preferred qualifications & skills
- Strong understanding of medical terminology, CPT/HCPCS procedure codes, ICD diagnosis codes, and insurance terminology.
- Knowledge of payer reimbursement methodologies and contract language, including Medicare, Medicaid, Workers’ Compensation, Managed Care, exclusions, case rates, percentages of charges, and fee schedules.
- Experience in orthopedic healthcare reimbursement highly preferred.
- Proficiency in interpreting explanation of benefits (EOBs) and tracing payer offsets, recoupments, and forward balances.
- Proficiency with EMR/EHR systems and the Microsoft Office Suite; basic Microsoft Excel skills required.
- Knowledge of basic accounting and mathematical principles, including the ability to calculate reimbursements and refund amounts.
- Strong written and verbal communication skills with the ability to interact professionally across departments and with external payers.
- Excellent attention to detail and a high level of accuracy.
- Strong organizational and time-management skills with the ability to prioritize work, multitask, and adapt to change.
- Ability to work independently while collaborating effectively with team members.
- Exercises discretion, sound judgment, and professionalism in all business relationships.
- Orthopaedic Solutions Management is a Drug Free Workplace
We are committed to maintaining a safe, healthy, and productive work environment. As part of this commitment, we operate as a drug-free workplace. All candidates will be required to undergo pre-employment drug screening and/or be subject to random drug testing in accordance with applicable laws and company policy.
