PFS Revenue Ops Specialist

Location: Burlington, MA
Job ID: 167312-1A
Date Posted: Apr 26, 2021
Category: Specialist

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Job Description

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

Performing a broad range of medical billing functions that cover an enterprise-wide scope, the PFS Revenue Billing Specialist role is responsible for identifying, researching and resolving various Professional and Hospital billing issues for all commercial and government payors. The Revenue Billing Specialist’s duties primarily involve registration error, coverage and eligibility related front-end edits and denials for both Professional and Hospital Billing. Additional tasks for Professional Billing include resolution of external clearinghouse edits, payor claim rejections, and disputed self-pay account balances. The role also includes frequent review and analysis of registration related issues and errors as well as education to reduce errors and denials and increase professional revenue.

Essential Duties & Responsibilities including but not limited to:

  1. Ensuring proper resolution of all registration, coverage and eligibility related issues captured within the following Epic billing workqueues:

    • Charge Review and Claim Edits queues used to resolve errors prior to claims submission and prevent denials.

    • Professional & Hospital Billing Denial queues that require insurance follow-up on coverage, eligibility, and coordination of benefits related denials in order to have each denied invoice reprocessed and reimbursed. 

    • Retro Review (Professional Billing) and Coverage Change Manager (Hospital Billing) queues to catch and apply potential retroactive coverage changes to outstanding visits, such as newly added coverages or filing order updates.

    • Remittance posting queues to properly match payments and eliminate undistributed credits by resolving invalid payor errors on a daily basis.

    • Account queues that hold disputed self-pay balances that have been escalated for further billing review.

  2. Under the guidance of the Department Manager and Supervisor and in accordance with departmental policies and standards, each Billing Specialist is expected to prioritize and maintain their daily assignments by applying filter and sort methods to their Epic billing workqueues.

  3. Responsible for independently and accurately posting all manual adjustments as necessary and selecting the appropriate adjustment codes. Adjustments exceeding certain situational thresholds as defined by department leadership will be sent to the Senior Manager for final review and approval.

  4. Responsible for the resolution of all external clearinghouse edits and payor rejections. 

  5. Makes necessary updates to the Epic patient registration and identifies opportunities to initiate rebilling of an entire account or multiple accounts associated with the same patient even if additional charges, claims, denials are not currently captured on their active workqueue list if it is deemed appropriate and if the end result produces a desirable and optimal outcome for both the department and the patient. 

  6. Attends and actively participates in monthly conference calls with an assigned physician group to provide operational billing support and ad-hoc workqueue training. Fields front-end user inquiries and provides accurate and timely responses.

  7. Responsible for performing a rigorous and detailed review of disputed self-pay account balances for complex billing scenarios that have been escalated by Customer Service after going unresolved.

  8. Works with departments throughout the organization, third party vendors and insurance carriers to resolve issues related to registration and customer inquiries.

  9. Maintains a proficient level knowledge of Physician and Hospital Billing regulations and requirements.

  10. Experienced with reading and interpreting CMS1500 and UB-04 claim forms.

  11. Works with Hospital, Professional and Customer Service departments to identify improper billing trends through root-cause analysis.

  12. Working in a SBO (Single Billing Office) environment the Revenue Billing Specialist will need to have in-depth knowledge of Hospital and Professional Billing workflows and in order to assist with customer on questions and accurate registration of insurance.

  13. Proactively identifies problems and opportunities for improvements related to system usage, training and end user education, practice and user trends and makes recommendations for workflow optimization and denial prevention.

  14. Collaborates with Revenue Cycle Analysts to validate observed patterns and trends with supporting data captured in Epic application and workbench reports.

  15. Assists in the development of reporting mechanisms to identify trends and track so that education can be performed to reduce and/or resolve high dollar/high volume values.

  16. Completes all assignments in accordance with department policy and the department standards.

  17. Attends meetings and serves on committees as requested.

  18. Achieves exemplary audit results and consistently exceeds productivity standards.

  19. Provides and promotes ideas geared toward process improvements within the Central Billing Office.

  20. Independently works on the resolution of complex claims issues, denials and appeals.

  21. Completes projects and research as assigned.

  22. Responsible for the mentoring and training of new and end existing A/R staff as it related to registration following the training program set forth to include but not limited to policy and procedures, Epic system functionality, audits and staff reviews

Additional Responsibilties:

  1. Enhances professional growth and development through in-service meetings, education programs, conferences, etc.
  2. Complies with policies and procedures as they relate to the job.  
  3. 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.
  4. 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.
  5. Accepts and learns new tasks as required and demonstrates a willingness to work where needed.
  6. Assists other staff as required in the completion of daily tasks or special projects to support the department’s efficiency.
  7. Performs similar or related duties as assigned or directed.

Minimum Qualifications:

Education:

Associates degree or equivalent experience

Licensure, Certification & Registration:

Billing Certification Preferred – Epic Resolute Professional/Hospital Billing Admin (Proficiency, Proficiency w/ Honors, or Certification)

Experience:

3 years of experience in registration billing and denial management environment related field or front end access related field. Experience in training and staff development preferred.

Skills, Knowledge & Abilities:

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

 

About Us

Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.

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