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
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 including but not limited to:
1. 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.
2. Analyzes work queues and other system report and identifies denial/non-payment trends and reports them to the supervisor.
3. 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. 4. Maintains open communication with third party payor representatives in order to resolve claim issues.
5. Utilize CAC or other electronic coder assisting tools available to validate proper coding of CPT/HCPCS/ICD-9/ICD-10 codes.
6. Identifies, reviews, and interprets third party denials
7. Initiates corrected claims and appeals according to payer guidelines.
8. Initiates denial write off when appropriate after thorough review.
9. Keeps abreast of all government, managed care and third party hospital coding, billing and reimbursement rules, regulations and guidelines.
10. Promotes Teamwork and maintains a positive atmosphere when communicating with fellow departmental colleagues both oral and written.
11. Completes all assignments per the turnaround standards. Reports unfinished assignments to the Supervisor.
12. Handles incoming department mail as assigned.
13. Attends meetings and serves on committees as requested.
14. Maintains appropriate audit results or achieves exemplary audit results. Meets productivity standards or consistently exceeds productivity standards.
15. Provides and promotes ideas geared toward process improvements within the Central Billing Office.
16. Assists the supervisor with the resolution of claims issues, denials, appeals and credits.
17. Works with the cash team to resolve unapplied cash.
18. Completes projects and research as assigned.
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. Ensures confidentiality of patient, budget, legal and company matters.
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 Billing Supervisor to ensure corrective measures are taken in a timely fashion.
5. Observes irregularities in the cash/denial posting process and reports them immediately to the Billing Supervisor.
6. Accepts and learns new tasks as required and demonstrates a willingness to work where needed.
7. Assists other staff as required in the completion of daily tasks or special projects to support the department’s efficiency.
8. Performs similar or related duties as assigned or directed.
High School Diploma or equivalent. Bachelor’s degree preferred 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.
Licensure, Certification & Registration: None required
Skills, Knowledge & Abilities:
1. Excellent customer service knowledge and skill
2. Working knowledge of Government and commercial health plan insurer coverage, claim requirements and remittance processing.
3. Understanding and ability to utilize various electronic, web based and manual coding resources
4. Ability performing transactions in a patient accounting system
5. Proficient data entry computer skills
6. Demonstrated ability to utilize word processing, spreadsheets and work files in performing work tasks 7. Strong communication skills including verbal in person, telephone and written
8. Demonstrated ability in being a cooperative and productive member of team
9. Ability to troubleshoot problems
10. Ability to continue to learn skills and expand knowledge
11. Strong organizational and planning skills
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.