Credit Refund Specialist - Remote - 139701

UC San Diego Health's Revenue Cycle department supports the organization's mission to deliver outstanding patient care and create a healthier world - one life at a time. We are a diverse, patient-focused, high-performing team committed to quality, collaboration, compliance, and continuous improvement. We offer challenging career opportunities in a fast-paced and innovative environment and welcome individuals who demonstrate strong problem-solving skills, accountability, accuracy, and customer service.

The Credit Refund Specialist is responsible for researching, validating, and resolving hospital credit balance accounts, insurance refund requests, overpayments, payer recoupments, and related account adjustments. This position requires strong hospital/facility billing knowledge, critical thinking, attention to detail, and the ability to determine whether a refund is appropriate based on claim history, payment activity, payer correspondence, contract terms, adjustment activity, and applicable state and federal requirements.

This role supports accurate reimbursement, appropriate account resolution, compliance with refund processing standards, and timely communication with payers and internal departments. The position requires sound judgment to identify unsupported or unclear refund requests, escalate complex accounts when needed, and ensure refunds are processed accurately and compliantly.

Key Responsibilities:

• Analyze hospital insurance credit balance accounts to ensure timely identification, validation, resolution, and issuance of accurate refunds when appropriate.
• Review insurance refund requests, payer correspondence, remittance activity, claim history, adjustments, and payment activity to determine whether a refund is supported.
• Review and interpret hospital payer contracts and reimbursement methodologies to verify expected reimbursement and identify discrepancies such as overpayments, underpayments, duplicate payments, or incorrect payer calculations.
• Research and resolve account credit balances related to coordination of benefits, retroactive eligibility changes, payer recoupments, duplicate payments, contract adjustments, payment posting discrepancies, and billing corrections.
• Respond professionally and effectively to inquiries from payers and internal departments regarding account balances, refund statuses, payment activity, and account resolution.
• Process insurance refund requests accurately and compliantly according to payer requirements, organizational standards, and applicable state and federal regulations.
• Identify, analyze, and resolve billing discrepancies, claim errors, payment variances, and account issues related to credit balances and refunds.
• Collaborate with internal teams, including billing, denials, payment posting, revenue integrity, contracting, coding, and patient access, to support accurate reimbursement and account reconciliation.
• Maintain clear, accurate, and compliant account documentation supporting refund decisions, account actions, and escalation outcomes.
• Maintain compliance with HIPAA regulations and ensure confidentiality and security of patient information throughout the refund and credit balance process.

• Three (3) years of acute care hospital billing, collections, payer follow-up, credit balance, refund, or account resolution experience.

• State and Federal rules and regulations related to facility medical insurance billing, claim processing, and refund handling.

• Demonstrated knowledge reviewing and resolving hospital claim errors, payment discrepancies, account balances, and payer correspondence.

• Thorough knowledge of UB04 and revenue codes as it pertains to hospital billing and reimbursement.

• Extensive knowledge in submission of hospital claims appeals and basic knowledge in medical terminology, ICD9, CPT, HCPCS coding principles.

• Demonstrated knowledge of facility reimbursement contracts and reimbursement methodologies including but not limited to per diem, fee schedule, case rate and DRG's.

• Demonstrated knowledge reviewing/processing facility insurance refund requests and account credit balances.

• Strong written and verbal communication skills, including the ability to document account activity clearly, accurately, and professionally.

• Demonstrated ability to manage high-volume account work while maintaining accuracy, productivity, compliance, and attention to detail.

• Recent hospital/facility credit balance and insurance refund processing experience.

• Recent Epic Resolute Hospital Billing experience.

• Experience researching and validating payer refund requests, overpayments, duplicate payments, coordination of benefits issues, retroactive eligibility changes, recoupments, underpayments, and payment discrepancies.

• Strong UB-04/CMS-1450 knowledge, including bill type, revenue codes, condition codes, occurrence codes, value codes, HCPCS/CPT codes, modifiers, diagnosis codes, and payer-specific facility billing requirements.

• Understanding of the relationship between revenue codes, HCPCS/CPT codes, payer reimbursement, payment posting, adjustment activity, and account credit balances.

• Experience reviewing remittance advice, payer correspondence, EOBs, claim status responses, refund letters, and account documentation to determine appropriate next steps.

• Critical thinking skills with the ability to determine whether a refund is supported, whether additional research is needed, or whether the account requires escalation.

• Experience identifying refund trends, payer calculation concerns, payment discrepancies, or process issues that may require internal review or payer follow-up.

• Familiarity with payer portals, document imaging systems, clearinghouse tools, claim status research tools, and account documentation workflows.

• Experience collaborating with billing, denials, payment posting, revenue integrity, contracting, coding, patient access, or payer representatives to resolve complex account balances.

• Understanding of hospital reimbursement concepts such as DRG, per diem, case rate, percent of charges, carve-outs, bundled services, and payer contract/payment methodology basics.

• Must be able to work various hours and locations based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.