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**Job Type:** Regular

**Time Type:** Full time

**Work Shift:** Day (United States of America)

**FLSA Status:** Non-Exempt

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

The PFS Denial Specialist I 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 PFS denials. Good writing and analytical skills are a must.

Job Description:

Essential Duties & Responsibilities including but not limited to:

1. Reviews and completes continuous daily work queue volume of PFS related denials. Monitors days in A/R and ensures that they are maintained at the levels expected by management.

2. Analyzes work queues and other system report and identifies denial/non-payment trends and reports them to the supervisor.

3. Responds to incoming insurance/office calls with professionalism and helps to resolve callers’ issues, retrieving critical information that impacts the resolution of current or potential future claims.

4. Maintains open communication with third party payor representatives in order to resolve claim issues.

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

6. Identifies, reviews, and interprets third party denials

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

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

9. Keeps abreast of all government, managed care and third party hospital coding, billing and reimbursement rules, regulations and guidelines.

10. Promotes Teamwork and maintains a positive atmosphere when communicating with fellow departmental colleagues both oral and written.

11. Completes all assignments per the turnaround standards. Reports unfinished assignments to the Supervisor.

12. Handles incoming department mail as assigned.

13. Attends meetings and serves on committees as requested.

14. Maintains appropriate audit results or achieves exemplary audit results. Meets productivity standards or consistently exceeds productivity standards.

15. Provides and promotes ideas geared toward process improvements within the Central Billing Office.

16. Assists the supervisor with the resolution of claims issues, denials, appeals and credits.

17. Works with the cash team to resolve unapplied cash.

18. Completes projects and research as assigned.

Secondary Function:

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.

Organizational Requirements:

Maintain strict adherence to the Lahey Health Confidentiality policy.

Incorporate Lahey Health Standards of Behavior and Guiding Principles into daily activities.

Comply with all Lahey Health Policies.

Comply with behavioral expectations of the department and Lahey Health.

Maintain courteous and effective interactions with colleagues and patients.

Demonstrate an understanding of the job description, performance expectations, and competency assessment.

Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

Participate in departmental and/or interdepartmental quality improvement activities.

Participate in and successfully completes Mandatory Education.

Perform all other duties as needed or directed to meet the needs of the department.

Minimum** **Qualifications:

Education: High School Diploma or equivalent. Bachelor’s degree preferred.

2-3 years’ experience in a hospital billing/coding, Denial Management environment related field.

Must have experience in either a hospital related billing, claims follow up environment or hospital coding.

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. Stong 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

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.

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