PBS Claims Specialist - Denial Management

Overview

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.

Responsibilities

• Resolve delinquent payment issues on complex, high-dollar, or specialty accounts requiring advanced knowledge of multi-payer systems.

• Investigate and evaluate patient account information, medical records, billing practices, and reimbursement regulations.

• Analyze accounts and, using independent judgment and input from PBS leadership, determine optimal follow-up actions to maximize reimbursement.

• Identify and remove barriers to claims processing, including rebilling, transferring payments, requesting refunds, or correcting misapplied payments.

• Negotiate financial arrangements and individual contracts with third-party payers, as directed by leadership.

• Follow Legacy procedures for writing off balances and processing adjustments appropriately.

• Utilize specialized Denial Management software, author appeal letters, and collaborate with internal departments on appeal documentation.

• Use an extensive library of online tools, payer resources, and internal databases to support denial resolution.

• Serve as a resource and mentor for team members on complex or high-impact cases.

• Consult with external legal counsel and payer representatives; attend hearings as needed to support claims resolution.

• Represent the Denial Management function in monthly Revenue & Reimbursement meetings and quarterly Utilization Review meetings.

• Track and report payer denial trends, collected reimbursement, and appeal activity to PBS management and other Legacy departments.

• Coordinate meetings with internal teams to improve communication and enhance overall Revenue Cycle operations.

Qualifications

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.

Pay Range

Our Commitment to Health and Equal Opportunity

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 encourage you to apply—even if you don't meet every qualification listed. 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.

To learn more about our employee benefits click here: www.legacyhealth.org/For-Health-Professionals/careers/benefiting-you