• Patient Financial Services Denial Specialist

    Alameda Health System (San Leandro, CA)


    Patient Financial Services Denial Specialist

    + San Leandro, CA

    + Finance

    + Patient Financial Svcs - Pro

    + Services As Needed / Per Diem - Day

    + $35.26 / Hour

    + Req #:41693-30873

    + FTE:0.01

    + Posted:May 15, 2025

    Summary

    **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. 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.

    2. Generate an appeal based on the dispute reason and contract terms specific to the payer. This includes online provider disputes and reconsiderations.

    3. Follow specific payer guidelines for appeals submissions, paying close attention to the timelines for appeals.

    4. Escalate exhausted appeal efforts for resolution.

    5. Work payer projects as directed.

    6. 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.

    7. Perform research and makes determination of corrective actions and takes appropriate steps and route account appropriately.

    8. Escalate denial or payment variance trends to the management team for payer escalation.

    9. Other duties as assigned.

     

    _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:

    Required Education: High school diploma or equivalent, some college coursework preferred.

     

    Minimum Experience: 3 - 5 years of experience in a hospital business environment performing billing and/or collections. OR two years of experience in a Revenue Cycle area within the Alameda Health System

     

    Alameda Health System is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military background.