Denial Specialist 1-Professional Billing

Job Description

The PFS Denial Specialist I role is vital to ensure that hospital denied accounts are thoroughly reviewed for any opportunity to correct, refile and or appeal claims for re-processing and reimbursement. The role also includes review and rework of all types of PFS denials. Good writing and analytical skills are a must.

Essential Duties & Responsibilities

• Reviews and completes continuous daily work queue volume of PFS related denials. Monitors days in A/R and ensures that they are maintained at the levels expected by management.
• Analyzes work queues and other system reports and identifies denial/non-payment trends and reports them to the supervisor.
• Responds to incoming insurance/office calls with professionalism and helps to resolve callers’ issues, retrieving critical information that impacts the resolution of current or potential future claims.
• Maintains open communication with third party payor representatives in order to resolve claim issues.
• Utilizes CAC or other electronic coder assisting tools available to validate proper coding of CPT/HCPCS/ICD-9/ICD-10 codes.
• Identifies, reviews, and interprets third party denials.
• Initiates corrected claims and appeals according to payer guidelines.
• Initiates denial write off when appropriate after thorough review.
• Keeps abreast of all government, managed care and third party hospital coding, billing and reimbursement rules, regulations and guidelines.
• Promotes teamwork and maintains a positive atmosphere when communicating with fellow departmental colleagues both oral and written.
• Completes all assignments per the turnaround standards. Reports unfinished assignments to the Supervisor.
• Handles incoming department mail as assigned.
• Attends meetings and serves on committees as requested.
• Maintains appropriate audit results or achieves exemplary audit results. Meets productivity standards or consistently exceeds productivity standards.
• Provides and promotes ideas geared toward process improvements within the Central Billing Office.
• Assists the supervisor with the resolution of claims issues, denials, appeals and credits.
• Works with the cash team to resolve unapplied cash.
• Completes projects and research as assigned.

Secondary Function

• Enhances professional growth and development through in-service meetings, education programs, conferences, etc.
• Complies with policies and procedures as they relate to the job. Ensures confidentiality of patient, budget, legal and company matters.
• Exercises care in the operation and use of equipment and reference materials. Performs routine cleaning and preventive maintenance to ensure continued functioning of equipment. Maintains work area in a clean and organized manner.
• Refers complex or sensitive issues to the attention of the Billing Supervisor to ensure corrective measures are taken in a timely fashion.
• Observes irregularities in the cash/denial posting process and reports them immediately to the Billing Supervisor.
• Accepts and learns new tasks as required and demonstrates a willingness to work where needed.
• Assists other staff as required in the completion of daily tasks or special projects to support the department’s efficiency.
• Performs similar or related duties as assigned or directed.

Organizational Requirements

• Maintain strict adherence to the Lahey Health Confidentiality policy.
• Incorporate Lahey Health Standards of Behavior and Guiding Principles into daily activities.
• Comply with all Lahey Health Policies.
• Comply with behavioral expectations of the department and Lahey Health.
• Maintain courteous and effective interactions with colleagues and patients.
• Demonstrate an understanding of the job description, performance expectations, and competency assessment.
• Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
• Participate in departmental and/or interdepartmental quality improvement activities.
• Participate in and successfully completes Mandatory Education.
• Perform all other duties as needed or directed to meet the needs of the department.

Qualifications

• Education: High School Diploma or equivalent. Bachelor’s degree preferred.
• Experience: 2-3 years’ experience in a hospital billing/coding, Denial Management environment related field. Must have experience in either a hospital related billing, claims follow up environment or hospital coding.
• Licenses, Certifications & Registrations: None required.
• Experience: Experience using patient accounting computer systems and Excel spreadsheets. Working knowledge of third party payer reimbursement, coding guidelines, and government and payer compliance rules.
• Skills, Knowledge & Abilities: Excellent customer service knowledge and skill; working knowledge of Government and commercial health plan insurer coverage, claim requirements and remittance processing; understanding and ability to utilize various electronic, web based and manual coding resources; ability performing transactions in a patient accounting system; proficient data entry computer skills; demonstrated ability to utilize word processing, spreadsheets and work files in performing work tasks; strong communication skills including verbal in person, telephone and written; demonstrated ability in being a cooperative and productive member of team; ability to troubleshoot problems; ability to continue to learn skills and expand knowledge; strong organizational and planning skills.

Pay Range

$22.05 – $29.68