PFS Denials and Appeals Specialist, FT, Days

Inspire health. Serve with compassion. Be the difference.

Job Summary

Responsible for pursuing denied accounts, timely and accurate follow-up to address and improve resolution of payment delays, updating / reprocessing claims, submitting reconsiderations / appeals within proper filing timeframe to achieve optimal payment for services rendered. Denials and appeals specialists must be knowledgeable of payer requirements, experienced in claim resolution, identify, expedite and escalate trends to management, demonstrate exceptional relationships with external / internal payers as well as internal departments in accordance with Prisma Health Standard of Behaviors and Compliance.

This is a remote position

Essential Functions

All team members are expected to be knowledgeable and compliant with Prisma Health's values : Inspire health. Serve with compassion. Be the difference.

Responsible for resolution of denied claims and / or initiate / manage / follow-up on reconsiderations / appeals in a timely manner. -

Monitors denial work queues and reports in accordance with assignments from direct supervisor and communicates all denial trends, denial increases, etc. to direct supervisor / PFS management in order to positively affect the volume of denials. Participates in departmental huddles and team meetings involving discussion of A / R processes and denial trends.

Maintains required levels of productivity and quality while managing tasks in work queues to ensure timeliness of follow-up and appeals.

Organizes denial / rejection related tasks to identify patterns and / or work most efficiently (e.g., by current procedural terminology, diagnosis, payer, etc.)

Identifies and monitors negative patterns in denials / rejections. Escalates accordingly to PFS management and the impacted department(s) to avoid negative impact on reimbursement, unsuccessful appeals, and / or increased write-offs.

Uses identified and known resources to accomplish follow-up on tasks. Identifies other means and resources to complete tasks, as applicable and appropriate. As needed, participates in A / R clean-up projects or other projects identified by direct supervisor or PFS management.

Comply with all government regulatory mandated requirements for billing and collections.

Works with other departments to resolve A / R and payer issues. Communicates with other departments on issues that may have negative impact on their cash flow, timely claim reconsideration / filing, failed appeals, and / or increased denials and write-offs.

Enters and documents appropriate accounts for adjustments utilizing the appropriate adjustment codes.

Identifies and researches all payer issues to the Payer SharePoint in a timely manner and continues to follow-up on said SharePoint information on a weekly basis.

Performs other duties as assigned.

Supervisory / Management Responsibility

This is a non-management job that will report to a supervisor, manager, director, or executive.

Minimum Requirements

Education - High School diploma or equivalent or post-high school diploma / highest degree earned

Experience - Five (5) years hospital / physician billing office and / or healthcare revenue cycle experience

In Lieu Of

In lieu of the education and experience requirements noted above, the following combination of education, training and / or experience may be considered an equivalent substitution : Bachelor's degree and two years of related work experience.

Required Certifications, Registrations, Licenses

Certified Revenue Cycle Analyst (CRCA) preferred

Knowledge, Skills and Abilities

Proficient computer skills (spreadsheets and excel pivot table skills)

Data entry skills

Mathematical skills

Medical terminology / ICD Coding

Knowledge of current trends and developments in the healthcare industry and specifically as it relates to denials / appeals through appropriate literature and professional development activities preferred

Self-motivation and ability to demonstrate initiative, excellent time management skills, and organizational capabilities and must be able to multi-task in a fast-paced environment and appropriately handle overlapping commitments and deadlines preferred

Ability to review / understand all pertinent information such as insurance carrier explanation of benefits, insurance carrier denial letters and electronic remits to ensure denials are worked in a timely manner and reconsideration / appeals for the denial claims are submitted appropriately preferred

Comprehensive understanding of remittance and remark codes preferred

Knowledge of payer edits, rejections, rules, and how to appropriately respond to each preferred

Working knowledge of UB-04 claim forms preferred

Work Shift

Day (United States of America)

Location

Corporate

Facility

7001 Corporate

Department

70019122 PBO-Patient Account Services

Share your talent with us! Our vision is simple : to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.