QA - Medical Billing Refunds

Description

Role SummaryThe Refunds Specialist is responsible for accurately identifying, validating, processing, and resolving refund-related accounts within the US Healthcare Revenue Cycle Management (RCM) process. The role requires strong knowledge of payment posting, accounts receivable, payer and patient transactions, overpayments, credit balances, and refund procedures. The specialist will ensure refunds are processed accurately, timely, and in accordance with client-specific SOPs and compliance requirements. Key Responsibilities· Review and analyze accounts with credit balances, overpayments, duplicate payments, incorrect payments, and patient or insurance refunds.· Validate refund requirements by reviewing account history, payment transactions, EOBs/ERAs, insurance payments, patient payments, adjustments, and previous refund activity.· Determine the appropriate action based on client SOPs and payer requirements.· Identify the source and reason for the credit balance or overpayment.· Validate whether the refund is due to insurance, patient, provider/facility, or other payment-related scenarios.· Ensure accurate documentation of refund decisions and supporting information.· Process refund requests within defined turnaround times and quality standards.· Identify and escalate complex or unusual refund scenarios.· Coordinate with AR, Payment Posting, Cash Applications, Operations, and client teams where applicable.· Maintain accurate refund trackers and documentation.· Identify recurring refund errors and recommend process improvements.· Ensure compliance with client SOPs, internal policies, HIPAA requirements, and applicable refund and payment guidelines. Eligibility Criteria· Minimum 2+ years of experience in US Healthcare RCM, preferably in AR, Payment Posting, Cash Applications, or a related process.· Minimum 1 years as active employee with Nimble solutions.· Anyone within RCM can apply for IJP.· Good communication both written & Verbal.· Attention to details· Willingness to work with multiple systems· Strong understanding of healthcare payment transactions.· Good knowledge of EOB/ERA, insurance payments, patient payments, adjustments, credit balances, overpayments, duplicate payments, and refund processing.· Consistent performance in the current role.· No active disciplinary action or performance-related concerns at the time of application.· Demonstrated ability to meet productivity and quality expectations. Skills Required· Strong analytical and problem-solving skills.· Excellent attention to detail.· Strong understanding of healthcare RCM.· Good understanding of payment and account reconciliation.· Ability to analyze account history and identify payment discrepancies.· Good written and verbal communication.· Proficiency in MS Excel.· Ability to manage multiple accounts and meet turnaround times.· Strong ownership and accountability.Requirements

Preferred Qualifications· Prior experience in Payment Posting, Cash Applications, AR, or Refunds.· Experience working with multiple healthcare specialties or facilities.· Knowledge of different payer types and payment methodologies.· Experience handling complex credit balances and overpayment scenarios.· Prior experience with account reconciliation or refund validation.Selection Process· Eligibility and performance screening· Refunds/RCM Knowledge Assessment· Refund Case Study / Account Analysis· Managerial Interview· Final selection based on overall performance and suitabilitySuccess Metrics – What Good Looks Like· High accuracy in refund identification and processing.· Correct validation of refund eligibility.· Timely resolution of assigned accounts.· Accurate account documentation.· Minimal rework and repeat errors.· Compliance with client SOPs.· Effective handling of complex refund scenarios.· Contribution to process improvement and error reduction.