Patient Financial Services Denial Specialist

Alameda Health Sytem; Oakland (CA); Sur place; USD 45 000 - 64 000; Temps partiel

Résumé du poste

Alameda Health System in Oakland, CA is seeking a part-time Patient Financial Services Denial Specialist internal only. The role validates dispute reasons, reviews EOBs, escalates payment variance trends to management, and generates appeals for denied and/or underpaid claims.

DUTIES include escalating denials, following payer guidelines and timelines, compiling documentation, ensuring accurate EHR coding, and coordinating with Revenue Integrity, HIM and ancillary departments as needed.

Qualifications

• Minimum 3–5 years in hospital billing/collections.
• Strong ability to manage multiple work queues daily.
• Ability to analyze trends and report to leadership.

Responsabilités

• Validate denial reasons and ensure accurate EHR coding.
• Escalate denial trends to management for payer escalation.
• Generate appeals per payer guidelines and timelines.
• Research contract terms and supporting docs for appeals.
• Coordinate with Revenue Integrity, HIM and ancillary departments.
• Work payer projects as directed.
• Perform data collection and report payer relations insights.
• Handle patient charges, payments and adjustments in a deadline-driven environment.
• Follow up on exhausted appeal efforts for resolution.

Connaissances

Excel

Word

Zoom

Communication

Formation

High school diploma/GED

Description du poste

Patient Financial Services Denial Specialist Internal Only

• Oakland, CA
• Finance
• Patient Financial Svcs - Pro
• Services As Needed / Per Diem - Day
• $39.2544
• Req #: 45098-33555
• FTE: 0.01

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.

• 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.