PBS Claims Specialist - Denial Management

At Legacy Health, our mission of making life better for others is at the heart of everything we do. As a Patient Business Services Specialist in Denial Management, you will help ensure that mission is fulfilled by resolving delinquent payment issues and negotiating financial arrangements. Your work helps maintain the integrity and efficiency of our claims process, allowing us to continue delivering high-quality care to our patients.

This role offers a meaningful opportunity to make a difference in the healthcare industry while growing your career in a supportive, compassionate environment.

Working under general supervision, the PBS Claims Specialist-Denial Management resolves delinquent payment issues of complex (high dollar and specialty) accounts requiring advanced knowledge of multi-payor system. Investigates and evaluates patient account information, medical records and bills, billing and reimbursement regulations. Analyzes each account and, using independent judgment and, in conjunction with PBS leadership, decides how to best proceed with followup to optimize reimbursement.

Removes barriers to processing claims. At the direction of PBS leadership, negotiates financial arrangements and individual contracts with third-party payors. Rebills, transfers payments, requests refunds or adjusts misapplied payments as necessary. Understands and follows Legacy procedures for writing off balances and adjustments.

Utilizes a specialized Denial Management software package, authors appeal letters, coordinates authoring appeals with other departments, and utilizes an extensive database of online tools and references. Serves as a resource for other team members, consults with outside counsel and provider representatives of health plans, and may attend hearings in person with payers. Represents the Denial Management Function on monthly Revenue & Reimbursement meetings, and attends meetings quarterly with the Utilization Review Department.

Compiles payer trends regarding denial activity, and reports on collected dollars and appeal review activity for PBS Management and various Legacy Departments wherein denial activity originates. Coordinates meetings with internal departments to enhance Revenue Cycle Operations.

Education:

Bachelor's Degree in business administration or healthcare operations administration or

equivalent experience required.

Experience:

Three years of directly applicable and progressively responsible healthcare business office experience (billing/credit/collection/denial management/appeals) required.

Skills:

• Demonstrated negotiating, problem-solving and decision-making skills.
• Demonstrated understanding of complex collection issues inherent in high dollar/specialty/denied accounts.
• Demonstrated knowledge of multi-payor systems.
• Demonstrated knowledge of billing/collection rules and regulations.
• Knowledge of online systems for eligibility and status review of claims.
• Net Typing of 40 wpm and PC based computer skills.
• 10 key proficiency.
• Knowledge of medical terminology.
• Ability to work efficiently with minimal supervision, exercising independent judgment within stated guidelines.
• Demonstrated effective interpersonal skills which promote cooperation and teamwork.
• Ability to withstand varying job pressures and organize/prioritize related job tasks.
• Excellent public relations skills and demonstrated ability to communicate in calm, businesslike manner.
• Ability to formally present to various groups.
• Ability to adapt to change.
• Ability to produce computer-generated reports using common office tools such as Microsoft Word, Excel, Access, and Powerpoint.

USD $27.12 - USD $38.77 /Hr.

Our Legacy is good for health for Our People, Our Patients, Our Communities, Our World. Above all, we will do the right thing.

If you are passionate about our mission and believe you can contribute to our team, we are committed to fostering an inclusive environment where everyone can grow and succeed.

Legacy Health is an equal opportunity employer and prohibits unlawful discrimination and harassment of any type and affords equal employment opportunities to employees and applicants without regard to race, color, religion or creed, citizenship status, sex, sexual orientation, gender identity, pregnancy, age, national origin, disability status, genetic information, veteran status, or any other characteristic protected by law.

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