Patient Financial Services Denials and Appeals Specialist

Responsibilities

• Responsible for pursuing denied accounts and timely follow‑up to address payment delays.
• Updating/reprocessing claims and submitting reconsiderations/appeals within proper filing timeframe.
• Knowledgeable of payer requirements and experienced in claim resolution.
• Identifying, expediting, and escalating trends to management.
• Demonstrating exceptional relationships with external/internal payers and internal departments.
• Monitoring denial work queues and reporting in accordance with assignments from direct supervisor.
• Participating in departmental huddles and team meetings involving discussion of A/R processes and denial trends.
• Maintaining required levels of productivity and quality while managing tasks in work queues to ensure timeliness of follow‑up and appeals.
• Organizing denial/rejection related tasks to identify patterns or work efficiently (e. g., by current procedural terminology, diagnosis, payer, etc.).
• Identifying and monitoring negative patterns in denials/rejections and escalating accordingly to PFS management.
• Utilizing identified and known resources to accomplish follow‑up on tasks.
• Complying with all government regulatory mandated requirements for billing and collections.

Requirements

• 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.
• Certified Revenue Cycle Analyst (CRCA) preferred.
• 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.
• 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.

Certifications & Qualifications

• Certified Revenue Cycle Analyst
• Industry Keywords
• healthcare revenue cycle
• denials
• appeals
• payer requirements
• billing and collections
• government regulatory compliance
• A/R processes
• hospital billing
• physician billing
• insurance carrier
• Tools & Technologies
• Excel
• pivot tables
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