General Member Reimbursement Specialist

Thank you for considering Progyny!

As a Reimbursement Specialist, you will be responsible for managing and processing a wide range of member reimbursement cases, including prescription (Rx) reimbursements and Financial Assistance Program (FAP) cases. This role requires reviewing and analyzing member cases, verifying reimbursements, and ensuring accurate and timely payment for services provided. You will also be tasked with communicating with members and internal teams to resolve billing issues, ensure compliance with regulatory guidelines, and maintain adherence to service level agreements (SLAs). The ideal candidate will have strong attention to detail, excellent communication skills, and the ability to manage multiple tasks effectively.  

What you’ll do...  

• Manage Reimbursement Cases: Handle 50–70-member reimbursement cases daily, ensuring the accurate and timely processing of medical and prescription (Rx) reimbursements in adherence to established service level agreements (SLAs).   

• Manage Financial Assistance Program (FAP) Cases: Oversee 20-30 Financial Assistance Program (FAP) cases, ensuring each is processed efficiently, meeting the expected SLAs. Collaborate with the Client Accounting Team and navigate the reimbursement process through to successful completion for each case.   

• Member Communication: Regularly communicate with members via email, providing timely updates and final case resolutions. Ensure all communication is clear, professional, and aligned with organizational standards.    

• Eligibility Report Review: Review and process bi-weekly ASRM eligibility trend reports that identifies incorrect Salesforce eligibility data Update health plans in Salesforce and makes necessary changes to member health plans, ensuring that all information is current and accurate for processing.  

•  Assist with Finance Operations: Provide support to the Member Collections Team by assisting with weekly check runs, ensuring that payments are made accurately and on time Works within Salesforce cases to update all relevant information.   

• Regulatory Compliance: Ensure that all cases and communications comply with applicable regulatory guidelines, industry standards, and internal policies.  

About you...

• Prior healthcare experience, ideally in the fertility industry, with a deep understanding of billing and reimbursement processes. Solid grasp of carrier billing, various insurance products, and benefits required.  

• Proven Experience with creating and processing medical and prescription claims for submission. 

• 1-3 years of demonstrated carrier billing experience and understanding of various insurance products and benefits. 

• Strong understanding of CPT, HCPCS, and ICD-10 codes, as well as medical terminology, required. 

• Strong understanding of formulary and non-formulary medications, particularly in the context of fertility treatments is a plus. 

• Strong attention to detail and ability to manage multiple priorities in a fast-paced, data-driven environment.  

• Comfortable with monthly performance feedback and motivated by meeting targets.  

• Flexible and able to adapt to change in a dynamic environment.  

• Skilled at managing difficult con