[Hiring] Patient Financial Services Denials & Appeals Specialist @Prisma Health

Role Description

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.

• 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.
• Communicates all denial trends, denial increases, etc. to direct supervisor/PFS management.
• 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.
• Organizes denial/rejection related tasks to identify patterns and/or work most efficiently.
• Identifies and monitors negative patterns in denials/rejections and escalates accordingly.
• Uses identified and known resources to accomplish follow-up on tasks.
• 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.
• 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.
• Performs other duties as assigned.

Qualifications

• High School diploma or equivalent or post-high school diploma / highest degree earned.
• Five (5) years hospital/physician billing office and/or healthcare revenue cycle experience.
• In lieu of the education and experience requirements noted above, a Bachelor's degree and two years of related work experience may be considered an equivalent substitution.
• Certified Revenue Cycle Analyst (CRCA) preferred.

Requirements

• 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 preferred.
• Self-motivation and ability to demonstrate initiative, excellent time management skills, and organizational capabilities preferred.
• Ability to review/understand all pertinent information such as insurance carrier explanation of benefits, insurance carrier denial letters and electronic remits 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.

Company Description

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.