Patient Financial Services Denial Specialist

About the position

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.

Responsibilities

• 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.
• Generate an appeal based on the dispute reason and contract terms specific to the payer. This includes online provider disputes and reconsiderations.
• Follow specific payer guidelines for appeals submissions, paying close attention to the timelines for appeals.
• Escalate exhausted appeal efforts for resolution.
• Work payer projects as directed.
• 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.
• Perform research and makes determination of corrective actions and takes appropriate steps and route account appropriately.
• Escalate denial or payment variance trends to the management team for payer escalation.
• Other duties as assigned.

Requirements

• High school diploma or equivalent, some college coursework preferred.
• 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.