PFS Denial Specialist 3

Beth Israel Lahey Health; Boston (MA); On-site; USD 33,269 - 44,772; Full time

Job summary

Beth Israel Lahey Health is seeking a Denial Specialist 3 in Boston, Massachusetts. This role focuses on resolving high-dollar and denied claims, ensuring accurate submissions and compliance with billing guidelines.

The ideal candidate will have at least three years of experience in denial management and a strong understanding of third-party payor reimbursement processes. This position offers a competitive hourly rate between $24.15 and $32.50 based on experience and shift differentials.

Qualifications

• 3 years of experience in a denial management environment.
• Strong knowledge of government and payor compliance rules.
• Experience in training and staff development.

Responsibilities

• Resolve back-end high dollar billing denials.
• Respond to customer service inquiries related to billing.
• Initiate rebilling and correct billing issues.
• Research active insurance coverages.
• Identify trends that lead to inappropriate billing.

Skills

Third-party payor reimbursement

Eligibility verification

Claims management

Training and staff development

Education

Associate degree or equivalent experience

Billing Certification (Preferred)

Job description

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

The Denial Specialist 3 role specializes in high-dollar claims, aged claims, and denied claims for complex specialties. This role identifies and works to resolve denials to uncover the root cause and accurately appeal claims to ensure successful initial submission. The Denial Specialist 3 will be responsible for charge and claim review to ensure the correct information is on the claim and it was billed appropriately. The Denial Specialist 3 will work directly with Supervisors and Managers to obtain the required information. Additional tasks include researching medical policies, payer billing guidelines, claim requirements, and written letters of medical necessity when required. This role also researches and resolves escalated, disputed self-pay balances. The Denial Specialist 3 will educate Supervisors & Managers on workflows to help optimize denial processing and prevent future denials.

Essential Duties & Responsibilities

• Responsible for working and resolving all back-end high dollar, complex, and aged physician billing denials as assigned. Reviews and completes continuous daily work queue volume for related denials.
• Responsible for working and responding to all customer service inquiries in regard to physician billing-related patient accounts as assigned.
• Responsible for work claim rejections due to physician billing-related issues returned by the payor preventing claims submission.
• Makes necessary updates to the Electronic Health Record (EHR) patient registration and initiates rebilling, correcting billing, or denials explanation back to customer service as assigned.
• Researches systems for active insurance coverages for self-pay balances beyond set thresholds to prevent missed cash collection opportunities.
• Works with departments throughout the organization, third-party vendors, and insurance carriers to resolve issues related to physician billing and customer inquiries.
• Works with Hospital, Professional, and Home Health Billing Teams when identifying trends that can lead to inappropriate billing to the customer.
• Working in an SBO (Single Billing Office), environment the Denial Specialist 3 will need to know Hospital and Professional Billing to assist customers with questions and accurate registration of insurance and or processing physician billing denials.
• Proactively identifies problems and opportunities for improvements related to system usage, training and end-user education, practice, and user trends and makes recommendations to the Manager of Revenue System Operations and partners with the Manager of EHR Training and/or the perspective departments with high volume/high dollar value for resolution.
• 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.
• Completes all assignments per the turnaround standards. Reports unfinished assignments to the Manager or Revenue Support.
• Attends meetings and serves on committees as requested.
• Achieves exemplary audit results and consistently exceeds productivity standards.
• Provides and promotes ideas geared toward process improvements within the Central Billing Office.
• Independently works on the resolution of complex claims issues, denials, and appeals.
• Completes projects and research as assigned.
• Provides support for the mentoring and training of new and existing A/R staff as required following the training program set forth to include but not limited to policy and procedures, EHR system functionality, audits and staff reviews.

Secondary Functions

• Enhances professional growth and development through in-service meetings, education programs, conferences, etc.
• Compliance with policies and procedures as they relate to the job.
• Exercise care in the operation and use of equipment and reference materials. Performs routine cleaning and preventive maintenance to ensure the continued functioning of equipment. Maintains work area in a clean and organized manner.
• 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.
• Accepts and learns new tasks as required and demonstrates a willingness to work where needed.
• Assists other staff as required in the completion of daily tasks or special projects to support the department’s efficiency.
• Performs similar or related duties as assigned or directed.

Minimum Qualifications

Education: Associate degree or equivalent experience.

Licensure, Certification & Registration: Billing Certification Preferred – EHR Professional/Hospital Billing Admin (Proficiency, Proficiency w/ Honors, or Certification).

Experience: Three (3) years of experience in denial management environment-related field. Experience in training and staff development.

Skills, Knowledge & Abilities: Strong knowledge of third-party payor reimbursement, eligibility verification process, and government and payor compliance rules.

Pay Range

$24.15 - $32.50 per hour (base hourly wage range). Actual compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable.

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) as a condition of employment.

Equal Opportunity Employer / Veterans / Disabled