| Location | Oakland, CA |
SUMMARY:The PFS Denial Specialist is responsible for validating dispute reasons following Explanation of Benefits (EOB) / Remittance Advice review, escalating payment variance trends and/or issues to management, and generating appeals for denied and/or underpaid claims.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level.Not all duties listed are necessarily performed by each individual in the classification.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Escalate denial or payment variance trends to the management team for payer escalation.
2. Escalate exhausted appeal efforts for resolution.
3. Follow specific payer guidelines for appeals submissions, paying close attention to the timelines for appeals.
4. Generate an appeal based on the dispute reason and contract terms specific to the payer. This includes online provider disputes and reconsiderations.
5. Other duties as assigned.
6. Perform research and makes determination of corrective actions and takes appropriate steps and route account appropriately.
7. Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for adjudication issues, and referrals to the lead or Supervisor for refund of overpayments.
8. Validate denial reasons and ensures coding in the EHR is accurate and reflects the denial reasons. Coordinate with Revenue Integrity, HIM, and the ancillary departments where necessary.
9. Work payer projects as directed.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
MINIMUM QUALIFICATIONS:
Minimum Experience: 3 - 5 years of experience in a hospital business environment performing Facility (HB) or Professional/Physician (PB) billing and/or collections.
Strong ability to effectively and efficiently manage multiple work ques during day-to-day operations
Strong ability to work and complete assigned responsibilities
Strong ability to analyze and identify trends, root cause opportunities and process improvements and report same to leadership
Strong ability to communicate relevant information to various stakeholders and functional teams in-person, email and Zoom
Knowledge of HIPPA requirements
Working kkowledge of clinical and billing regulations
Strong ability to perform data collection and demonstrate effective payer relations
Demonstrate proficient skill sets in Excel and Word
Strong Zoom meeting presentation skills including regular contributions and attendance
Strong ability with mathematical analysis
Strong ability to investigate patient charges, payments and adjustments in a highly productive & deadline driven environment
Required Education: High school diploma/GED or some higher education preferred.