Patient Financial Services Denial Specialist

Alameda Health System•Oakland, CA

About The Position

The PFS Denial Specialist validates dispute reasons after reviewing Explanation of Benefits (EOB) and Remittance Advice, escalates payment variance trends and issues to management, and prepares appeals for denied or underpaid claims. The role researches payer contract terms and denial issues, determines corrective actions, routes accounts appropriately, and works with Revenue Integrity, HIM, and ancillary departments as needed. The specialist also supports payer projects and may perform other related duties at an equivalent level.

Requirements

Three to five years of experience in a hospital business environment performing Facility (HB) or Professional/Physician (PB) billing and/or collections.
Ability to manage multiple work queues effectively and efficiently during day-to-day operations.
Ability to complete assigned responsibilities.
Ability to analyze and identify trends, root-cause opportunities, and process improvements, and report findings to leadership.
Ability to communicate relevant information to stakeholders and functional teams in person, by email, and through Zoom.
Knowledge of HIPAA requirements.
Working knowledge of clinical and billing regulations.
Ability to perform data collection and demonstrate effective payer relations.
Proficiency in Excel and Word.
Strong Zoom meeting presentation skills, including regular contributions and attendance.
Ability to perform mathematical analysis.
Ability to investigate patient charges, payments, and adjustments in a highly productive, deadline-driven environment.

Nice To Haves

Some higher education.

Responsibilities

Escalate denial and payment variance trends to management for payer escalation.
Escalate exhausted appeal efforts for resolution.
Follow payer-specific appeal submission guidelines and timelines.
Generate appeals based on dispute reasons and payer-specific contract terms, including online provider disputes and reconsiderations.
Research issues, determine corrective actions, take appropriate steps, and route accounts appropriately.
Research contract terms and interpretations; compile supporting documentation for appeals and Terms & Conditions for adjudication issues; refer overpayment refund matters to the lead or Supervisor.
Validate denial reasons and ensure EHR coding accurately reflects them.
Coordinate with Revenue Integrity, HIM, and ancillary departments when necessary.
Work on payer projects as directed.
Perform other duties as assigned.