Refund Specialist

Position Title: Refund Specialist
Department: Revenue Cycle Management
Reports To: Cash Application Team Lead
FLSA: Non Exempt

Position Summary
The Refund Specialist is responsible for investigating, validating, processing, and tracking insurance and patient refund requests, recoupments, and payment take-backs while ensuring accuracy, compliance, and financial integrity. This role partners closely with Cash Posting, Accounts Receivable, Coding, and other revenue cycle teams to research complex account and claim activity, determine the validity of refund and recoupment requests, identify opportunities for appeals or disputes, and analyze payer trends to improve reimbursement outcomes and reduce future recoupment activity. Success in this position requires strong analytical skills, medical accounts receivable expertise, and the ability to independently resolve complex payment and reimbursement issues.

Essential Duties & Responsibilities

• Refund Investigation & Resolution
  • Investigate and validate insurance and patient refund requests to determine legitimacy, accuracy, and compliance with organizational policies.
  • Review account histories, payment records, EOBs, claims documentation, and payer correspondence to support refund determinations.
  • Process approved refunds and ensure all supporting documentation is complete and accurately maintained.
  • Document findings, account activity, communications, and refund resolutions in appropriate systems.
  • Coordinate with patients, insurance carriers, patient advocates, and internal stakeholders regarding refund decisions and next steps.
• Recoupment & Take-Back Management
  • Investigate insurance recoupments, take-backs, and overpayment recovery requests to determine validity and financial impact.
  • Research payer actions and supporting claim data to determine whether recoupments should be accepted, disputed, or appealed.
  • Identify and escalate questionable reimbursement activity, unsupported overpayment requests, and high-risk payer actions to leadership.
  • Serve as the primary resource for reviewing complex recoupment scenarios that require detailed investigation beyond standard payment posting activities.
• Analysis, Reporting & Process Improvement
  • Participate in Clinical Support, Audit, and Ticket programs
  • Track, monitor, and maintain reporting related to refund requests, recoupments, payer recoveries, and reimbursement trends.
  • Analyze recurring payer behaviors, claim types, procedures, coding patterns, and reimbursement issues to identify root causes of refund and recoupment activity.
  • Provide ongoing reporting and recommendations to leadership regarding opportunities reduce revenue loss and improve financial outcomes.
  • Partner with Cash Posting, Accounts Receivable, Coding, and Revenue Cycle leadership to implement process improvements and corrective actions.
  • Assist in developing best practices, workflows, and operational strategies to improve refund management and payer accountability.
• Documentation, Compliance & Collaboration
  • Maintain organized audit trails and supporting documentation for all refund and recoupment activity.
  • Ensure compliance with HIPAA, payer requirements, company policies, and internal financial controls.
  • Collaborate closely with the Cash Application Team Lead and Revenue Cycle stakeholders to support organizational reimbursement goals and revenue integrity initiatives.
  • Perform additional duties and special projects as assigned.

Qualifications & Requirements
Education Licenses/Certifications

• High School Diploma or GED required.
• Bachelor's degree preferred.

Experience

• 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.

Skills & Competencies

• Strong knowledge of healthcare revenue cycle operations, including accounts receivable, insurance reimbursement, claim adjudication, and resolution of complex refund and recoupment issues.
• Excellent communication and collaboration skills, working effectively with insurance carriers, patients, and cross-functional revenue cycle teams to resolve claims, appeals, and reimbursement disputes.
• Strong analytical skills with the ability to research payer activity, interpret EOBs, review claims, identify root causes, and recommend strategies to improve reimbursement outcomes.
• Proficiency in CPT, ICD-10, and HCPCS coding concepts, Microsoft Office, payer portals, healthcare billing systems, and documentation tools, with strong attention to detail and ability to manage priorities in a fast-paced environment.

Working Conditions

• Primarily remote office environment with frequent and prolonged computer and office equipment use.
• Standard business hours with occasional overtime to meet project deadlines.
• Ability to manage stress and maintain productivity under tight deadlines and changing priorities.
• Regular interaction with team members, clients, and other stakeholders through various communication channels.
• Occasional travel required for company meetings.

Physical Demands

• Ability to maintain a stationary position for extended periods.
• Occasionally required to move short to moderate distances.
• Must be able to lift and/or move up to 50 pounds occasionally.

Disclaimer: The statements herein are intended to describe the general nature and level of work being performed by employees and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Employees must be able to perform the essential functions of the position satisfactorily. Furthermore, the statements do not establish a contract for employment and are subject to change at the discretion of the Company with or without advance notice.