ABOUT US

Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.

Position Summary

The Reimbursement Specialist, Provider Data Management is responsible for taking a leading role in the coordination and loading of all physicians, hospital, and ancillary contracts for all Medicaid and Medicare clients.

Essential Functions

1. Responsible for the data integrity of all provider set-ups and reimbursement configurations 
2. Responsible for all practitioner, hospital and ancillary contracts loaded into the claims system.
3. Implement provider contracts and/or contract amendments and conduct claims testing.
4. Program reimbursement setups applicable to the contract specifications. This includes fee for service pricing, capitation, pricing methods appropriate for office based, inpatient, outpatient, ambulatory, and emergency room settings.
5. Responsible for timely and accurate research of resources that update critical information on a scheduled basis.
6. Assist with ad hoc projects as necessary to meet client needs.
7. Create and document workflows and policies and procedures (P&Ps) as necessary.
8. Participate in client implementation and conversion projects.
9. Represent the department by actively participating in internal meetings, external (client) meetings, and work sessions.
10. Assist in creating and maintaining all pricing setups in the claims system and ensure all updates are processed timely and accurately.
11. Serve as mentor and support to the staff in interpreting and implementing complex contract configurations into the claims system.
12. Troubleshoot provider set-ups as necessary, in support of the claim processing operation.
13. Conduct other duties as requested by department management to assure efficient company operations.
14. Client contact required.

Education and Experience

• Associate degree minimum or equivalent experience.
• Minimum four (4) years industry experience required.
• Experience in processing UB-04 / CMS 1500 claims required.
• Familiarity and understanding of provider contracts.
• Knowledge of company’s proprietary claim systems preferred. 
• Must possess good understanding of claim adjudication process including ICD, CPT, HCPCS
• Proficient knowledge of UB04 / CMS-1500 claim adjudication process, including Medicare and Medicaid reimbursement methodologies (i.e. Per Diem, PPS, FFS, APG, Capitation, etc.) required.
• Excellent verbal and written communication skills required.
• Computer proficiency in Microsoft applications (i.e. Excel and Access.) required.
• Ability to travel (infrequent)

Required Skills

• Ethical Conduct. 
• Strategic-Critical Thinking. 
• Leadership.
• Decision Making. 
• Financial Management. 
• Communications Proficiency. 
• Presentation Skills.

EEO STATEMENT 

In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. Independent Living Systems, LLC, and its subsidiaries, including FCC, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.