PFS Medical Billing Representative 2

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Location: Burlington, MA
Job ID: 156906-1A
Date Posted: Aug 29, 2019
Category: Specialist

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Job Description

Welcome To

Lahey Health Shared Services is part of a vibrant and growing health care system, recognized as a trailblazer in medicine and a standard bearer in patient experience. It includes an award-winning academic medical center, a superb constellation of community hospitals, home care services, rehabilitation facilities and more.

We are committed to attracting, developing and retaining top talent in a market long recognized and revered as a global leader in health. With a team approach to care, we encourage learning and growth at all levels, and we offer competitive salaries and benefits. We adhere to the principles of a just and fair work environment for all colleagues, where respect is foundational and performance is rewarded.

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 to resolve complex issues, denials, appeals and refunds through independent research and assigned projects. Assists in the development of staff training programs and is responsible for overall staff training and mentoring of new hires and peers.


  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.
  • 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 or corrections and obtains and submits information necessary to ensure account resolution/payment
  • Identifies invalid account information (i.e.: coverage, demographics, etc.) and resolves issues.
  • 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.
  • Processes and completes refund requests through accounts payable.
  • Completes all manual and electronic insurance payment posting assignments per the turnaround standards. Reports unfinished assignments to the Billing Supervisor.
  • 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.
  • 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.
  • Responsible for the development and continued growth of new hire training.
  • Responsible for the training of staff in identified areas of need.
  • Responsible for the mentoring and training of new and end existing A/R staff following the training program set forth to include but not limited to policy and procedures, Epic system functionality, audits and staff reviews

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.



  • High School diploma required, bachelor’s degree preferred

Licensure, Certification & Registration:

  • Billing Certification preferred


  • 4 years of experience in billing or related field preferred

Skills, Knowledge & Abilities:

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

About Us

The Lahey Model of Care—right care, right time, right place—is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

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