Refund Specialist
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Job Description
Refund Specialist investigating healthcare refunds, recoupments, and payer overpayments. Analyzing claims and reimbursement trends to protect revenue integrity and improve financial outcomes.
Responsibilities:
- Investigate and validate insurance and patient refund requests for legitimacy, accuracy, and compliance
- Review account histories, payment records, EOBs, claims documentation, and payer correspondence
- Process approved refunds and maintain complete supporting documentation
- Document findings, account activity, communications, and refund resolutions in appropriate systems
- Coordinate with patients, insurance carriers, patient advocates, and internal stakeholders
- Investigate insurance recoupments, take-backs, and overpayment recovery requests
- Determine whether recoupments should be accepted, disputed, or appealed
- Escalate questionable reimbursement activity, unsupported overpayment requests, and high-risk payer actions
- Review complex recoupment scenarios beyond standard payment posting activities
- Participate in Clinical Support, Audit, and Ticket programs
- Track and report refund requests, recoupments, payer recoveries, and reimbursement trends
- Analyze payer behaviors, claim types, procedures, coding patterns, and reimbursement issues to identify root causes
- Provide reporting and recommendations to leadership to reduce revenue loss and improve financial outcomes
- Partner with Cash Posting, Accounts Receivable, Coding, and Revenue Cycle leadership on process improvements and corrective actions
- Develop best practices, workflows, and operational strategies for refund management and payer accountability
- Maintain audit trails and supporting documentation for refund and recoupment activity
- Ensure compliance with HIPAA, payer requirements, company policies, and internal financial controls
- Collaborate with the Cash Application Team Lead and Revenue Cycle stakeholders
- Perform additional duties and special projects as assigned
Requirements:
- High School Diploma or GED required
- Bachelor's degree preferred
- Minimum of three (3) years of medical accounts receivable, revenue cycle, refunds, payment posting, or related healthcare reimbursement experience required
- Experience investigating insurance claims, overpayments, refunds, denials, appeals, or recoupments preferred
- Strong understanding of medical billing, claims processing, and payer reimbursement methodologies
- Strong knowledge of healthcare revenue cycle operations, including accounts receivable, insurance reimbursement, claim adjudication, and complex refund and recoupment issues
- Strong analytical skills with the ability to research payer activity, interpret EOBs, review claims, identify root causes, and recommend reimbursement strategies
- Proficiency in CPT, ICD-10, and HCPCS coding concepts, Microsoft Office, payer portals, healthcare billing systems, and documentation tools
- Excellent communication and collaboration skills
- Strong attention to detail and ability to manage priorities in a fast-paced environment
- Ability to manage stress and maintain productivity under tight deadlines and changing priorities
- Ability to maintain a stationary position for extended periods
- Must be able to lift and/or move up to 50 pounds occasionally
Benefits:
- Fully remote work arrangement
- Occasional travel for company meetings
- Standard business hours with occasional overtime to meet project deadlines
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