Reimbursement Manager - Healthcare Claims, Denials, Revenue Ops

The Program Reimbursement Manager is responsible for leading and optimizing reimbursement operations across the organization’s programs and services.

This position oversees claims processing, denial management, reimbursement performance, regulatory compliance, and revenue optimization. The Manager leads and develops the reimbursement team, monitors key performance indicators, identifies opportunities to reduce revenue leakage, and partners with internal and external stakeholders to ensure timely and accurate reimbursement.

Core Duties/Responsibilities:

• Claims Processing & Management: Oversee the timely and accurate submission, processing, follow-up, and resolution of claims while ensuring compliance with payer requirements and applicable reimbursement regulations.
• Develop and implement strategies to maximize reimbursement and reduce revenue leakage.
• Analyze reimbursement trends, identify opportunities, and make recommendations for continuous process improvement.
• Ensure compliance with healthcare regulations, such as HIPAA, Medicare, and Medicaid.
• Monitor claim denials while collaborating with internal team members and external stakeholders such as insurance providers and government agencies to resolve.
• Develop and maintain relationships to ensure successful reimbursement outcomes.
• Act as a liaison between the organization and key stakeholders: Collaborate with healthcare providers, billing departments, and insurance companies to resolve reimbursement-related issues.
• Keep abreast of codes, fee schedules, and changes in reimbursement guidelines and adjust processes accordingly.
• Provide team leadership, development, training, and support to staff on reimbursement policies and procedures.
• Additional responsibilities include but are not limited to team performance reviews, training, ongoing coaching, and planning for coverage needs.

Skills / Requirements:

• Experience in people-management and leading remote teams across various time zones.
• Strong knowledge of healthcare reimbursement regulations and policies.
• Proficiency in healthcare billing and coding.
• Excellent analytical, problem-solving, and decision-making skills.
• Effective communication and interpersonal skills.
• Detail-oriented with a focus on accuracy and compliance.
• Strong proficiency in relevant software and data analysis tools.

Education, Certifications and Experience:

• Bachelor's degree in healthcare administration, business, or a related field (Master's degree preferred).
• 5+ years of experience in healthcare reimbursement, with a proven track record of successful management.
• Proficiency in Microsoft Excel to analyze and report revenue cycle data and
• Proficiency in Microsoft PowerPoint to create presentations communicating key metrics, trends and operational performance to leadership.

Physical Requirements: 

• As a remote-forward organization, this position operates in a virtual professional office environment and teleworking from the employee’s home address listed in their employment file.
• Prolonged periods of sitting at a desk and working on a computer
• Keyboarding
• Speaking
• Must be able to lift up to 15 pounds at times
• Flexibility of working hours to support activities across EST to PST zones
• Minimal travel possible.

Our PRO-spectus Culture Philosophy

At PRO-spectus we have created a culture that is supportive, dedicated, and teamwork driven.  We celebrate each other’s joys in personal life and professional accomplishments, promoting meaningful relationships and friendships. 

Our employees bring strength of mind and spirit to make the extraordinary happen every day.  With humility and compassion at our core, PRO-spectus is proud of our relentless focus towards the higher purpose of improving the lives of patients we support.

We recognize it takes a lot of people working together with a common goal to make spectacular happen, and we never forget that at the heart of our company are the people who make it work.

PRO-spectus is an Equal Opportunity / Affirmative Action employer. All qualified individuals will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, protected veteran status, marital status or other protected status under federal, state or local laws.1

At PRO-spectus, we are deeply committed to pay transparency and equity. The annual range for this position is $92,000 - 100,000, based on experience and qualifications, with the final offer reflecting skills and other job-related factors. Beyond competitive pay, we offer a comprehensive and generous benefits package designed to support your well-being and work-life balance. 

Our benefits include robust medical, dental, and vision plans; life insurance and disability coverage; and tax-advantaged savings accounts. We also provide an Employee Assistance Program, home office benefits, and unique perks like an Employee Ownership Program. With paid time off, holidays, bereavement leave, and a 401(k)-retirement plan with employer matching, PRO-spectus prioritizes your financial and personal security. Plus, you may be eligible for a performance-based bonus opportunity. 

Join PRO-spectus, where your career growth, well-being, and contributions truly matter!