PFS Denial Specialist I

Welcome To

Welcome to Shared Services, our team uses a coordinated approach to delivering administrative and operational services across Lahey. Our Shared Services colleagues leverage resources across the organization to ensure we provide high-quality, high-value care to the communities we proudly serve. The Shared Services team includes colleagues who focus on business and network development, legal services, facilities and real estate, human resources, information technology, finance, philanthropy and marketing and communications.

About the Job

Identifies, reviews, and interprets third party payments, adjustments and denials. Initiates corrected claims, appeals and analyzes unresolved third party and self-pay accounts, initiating contacts and negotiating appropriate resolution (internal and external) to ensure timely and maximum payment. Manually and electronically applies insurance payments and works insurance overpayments, credits and undistributed balances. Works directly with the Billing Supervisor to resolve complex issues and denials through independent research and assigned projects.

Essential Duties & Responsibilities including but not limited to:

• 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 Billing Supervisor.
• Ability to navigate the hospital billing system in order to identify paid claims or root cause of denial when assessing physician inpatient denials.
• 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.
• Establishes relationships and maintains open communication with third party payor representatives in order to resolve claims issues.
• Reviews claim forms for the accuracy of procedures, diagnoses, demographic and insurance information, as well as all other fields on the CMS 1500.
• Reviews and corrects all claims/charge denials and edits that are communicated via Epic, Explanation of Benefits (EOB), direct correspondence from the insurance carrier or others and uses information learned to educate PFS and office staff to reduce future denials and edits of the same nature. Initiates claim rebilling, written appeals or corrections and obtains and submits information necessary to ensure account resolution/payment
• Evaluates delinquent third party accounts and processes based on established protocols for review, payment plan or write-off.
• Reviews/updates all accounts for write-offs and refunds.
• Reviews and follows through on all insurance credit balances through take back initiation, refund initiation, and/or payment re-application.
• Keeps informed of all federal, state, and managed care contract regulations, maintains working knowledge of billing mechanics in order to properly ascertain patients’ portion due.
• Completes all assignments per the turnaround standards. Reports unfinished assignments to the Billing Supervisor.
• Handles incoming department mail as assigned.
• Attends meetings and serves on committees as requested.
• Maintains appropriate audit results or achieves exemplary audit results. Meet productivity standards or consistently exceeds productivity standards.
• Provides and promotes ideas geared toward process improvements within the Central Billing Office.
• Assists the Billing Supervisor with the resolution of complex claims issues, denials, appeals and credits.
• Works with cash team to resolve unapplied cash.
• Completes projects and research as assigned.

Secondary Functions:

• 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.

Education:

• High School diploma required

Licensure, Certification & Registration:

• Billing Certification preferred

Experience:

• 2 – 3 years of experience in healthcare denials.

Skills, Knowledge & Abilities:

• Working knowledge of third party payor reimbursement, eligibility verification process and government and payor compliance rules.

About Us

Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve. Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health. Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.