Open position

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:

Regular

Scheduled Hours:

40

Work Shift:

Day (United States of America)

The PFS Denial Specialist II 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 denials, as well as analysis and education to reduce denials and increase hospital reimbursement. Mentoring and coaching skills are a must.

Job Description:

Essential Duties & Responsibilities including but not limited to:

1. Reviews and completes continuous daily work queue volume of all PFS related denials.

2. Proactively identifies problems or opportunities for improvements related to orders and/or documentation and makes recommendations to Manager and/or the perspective departments with high volume/high dollar values.

3. Utilize CAC or other electronic coder assisting tools available to validate proper coding of CPT/HCPCS/ICD-9/ICD-10 codes.

4. 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.

5. Develop strong working relationships with other Lahey Health department personnel to promote clear communication and welcomed education for reimbursement enhancement.

6. Identifies, reviews, and interprets third party denials.

7. Initiates corrected claims and appeals according to payer guidelines.

8. Responds to incoming payer and patient calls as warranted

9. Research and compile data for unresolved denial issues and escalates to a denial analyst for further review as well as upper management.

10. Initiates denial write off when appropriate after thorough review.

11. Keeps informed of all federal, state and managed care contract regulations.

12. Acts as a mentor and provides teaching to new hires as well as refreshers for current employees

13. Responsible for auditing new hires during teaching and mentoring to ensure clear understanding of policies, workflows, and procedures.

14. Assist team members with denial or follow up questions prior to escalation to leadership

15. Work special projects assigned by Director/Manager/Supervisor

16. Reviews and updates provider escalation grids for submissions monthly or sooner as needed

17. Assists in reviewing appeals compiled by PFS Denial Specialist I to ensure accuracy prior to leadership approval

18. Review medical record request and compile required documentation for submission to payer

Secondary Functions:

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.

Minimum Qualifications:

Education:

• High School Diploma required. Bachelor degree preferred.
• 3 years of patient account experience either in a hospital or professional setting.
• Working knowledge of third party reimbursement, eligibility verification process, and government and payer compliance rules.

Licensure, Certification & Registration: None required

Experience: Experience using patient accounting computer systems and Excel spreadsheets. Working knowledge of third party payer reimbursement, coding guidelines, and government and payer compliance rules

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

FLSA Status:

Non-Exempt

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled