PFS Denial Specialist 3

Job Description

• Responsible for working and resolving all back-end high dollar, complex, and aged physician billing denials as assigned.
• Reviews and completes continuous daily work queue volume for related denials.
• Responsible for working and responding to all customer service inquiries in regard to physician billing-related patient accounts as assigned.
• Responsible for work claim rejections due to physician billing-related issues returned by the payor preventing claims submission.
• Makes necessary updates to the Electronic Health Record (EHR) patient registration and initiates rebilling, correcting billing, or denials explanation back to customer service as assigned.
• Researches systems for active insurance coverages for self-pay balances beyond set thresholds to prevent missed cash collection opportunities.
• Works with departments throughout the organization, third-party vendors, and insurance carriers to resolve issues related to physician billing and customer inquiries.
• Works with Hospital, Professional, and Home Health Billing Teams when identifying trends that can lead to inappropriate billing to the customer.
• Proactively identifies problems and opportunities for improvements related to system usage, training and end-user education, practice, and user trends and makes recommendations to the Manager of Revenue System Operations and partners with the Manager of EHR Training and/or the perspective departments with high volume/high dollar value for resolution.
• Completes all assignments per the turnaround standards. Reports unfinished assignments to the Manager or Revenue Support.
• Attends meetings and serves on committees as requested.
• Achieves exemplary audit results and consistently exceeds productivity standards.
• Provides and promotes ideas geared toward process improvements within the Central Billing Office.
• Independently works on the resolution of complex claims issues, denials, and appeals.
• Completes projects and research as assigned.
• Provides support for the mentoring and training of new and end existing A/R staff as required following the training program set forth to include but not limited to policy and procedures, EHR system functionality, audits and staff reviews.

Secondary Functions

• Enhances professional growth and development through in-service meetings, education programs, conferences, etc.
• Compliance with policies and procedures as they relate to the job.
• Exercise care in the operation and use of equipment and reference materials. Performs routine cleaning and preventive maintenance to ensure the continued functioning of equipment. Maintains work area in a clean and organized manner.
• Refers complex or sensitive issues to the attention of the Manager of Revenue System Operations to ensure corrective measures are taken in a timely fashion.
• 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.

Minimum Qualifications

• Education: Associate degree or equivalent experience
• Licensure, Certification & Registration: Billing Certification Preferred – EHR Professional/Hospital Billing Admin (Proficiency, Proficiency w/ Honors, or Certification
• Experience: Three (3) years of experience in denial management environment-related field. Experience in training and staff development
• Skills, Knowledge & Abilities: Strong knowledge of third-party payor reimbursement, eligibility verification process, and government and payor compliance rules.