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PFS Claims Management Analyst - 40 hrs/wk.

Company: Blanchard Valley Health System
Location: Findlay
Posted on: May 28, 2023

Job Description:


The purpose of the PFS Claims Management Analyst is to provide support to Patient Financial Services and other departments with complex functions related to billing and denials. The Claims Management Analyst will serve as a primary liaison between the staff and organizational management, develop and generate necessary reporting of metric performance and enhance the current claims edit process within our claim software system that have resulted in prevention of a clean claim submission or re-submission on behalf of Blanchard Valley Health System The Claims Management Analyst will trend and perform analysis on these edit failures and develop resolution across the organization.


  • Duty 1.Develops and presents various billing and denial key performance metrics and productivity dashboards to identify resolution opportunity and workflow improvement in high dollar risk areas.
  • Duty 2.Effectively audits reports claim rejections to perform root cause analysis of billing and departmental staff claims processing delays, billing/payer related concerns and develop detailed action plans in efforts of maximizing the organizational clean claim rate and overall reimbursement.
  • Duty 3.Creates and develops process improvement by creating, maintaining, and effectively presenting self-identified statistics to organizational stakeholders with aging, high dollar, and high-volume edits in efforts to resolve and create acceleration of future claims for optimized payment efforts.
  • Duty 4.Serves as the lead point of resolution support for the billing and denial staff including, but not limited to, payer policies, payer/organizational contracts, billing edits and process improvement opportunities.
  • Duty 5.Coordinates and discusses complex data analysis between Patient Financial Services, Revenue Integrity, Managed Care and various departmental leadership teams. Ensures accurate system access and completion or assistance of required education and training for stakeholders.
  • Duty 6.Develops and facilitates regular scheduled task force meetings and ensures reports are distributed in advance to departmental stakeholders timely. Prepares for meetings by performing a deep dive analysis at both an aggregate as well as a detailed level to identify trending, potential risks, and negative financial impacts.
  • Duty 7.Actively participates in continuing education opportunities to remain familiar with organizational and healthcare industry changes to ensure compliant measures. Utilizes project management resources and tools to remain current in and promote industry best practices.
  • Duty 8.Provides advanced support, including but not limited to; billing & denial related patterns and trends, identifying, and implementing payer issue resolution including Quadax payer matching, researches and identifies industry standard metrics and develops ongoing tracking and monitoring of such metrics, and provides necessary training and education around these functions.
  • Duty 9.Assures confidentiality of patient information. Maintains compliant documentation and records in accordance with Federal and State regulations in patient account files. Accurately documents all account activity. Adheres to all HIPAA related privacy, security and transaction & code set regulations in compliance with the Federal guidelines.
  • Duty 10.Upholds Blanchard Valley Health System's mission, vision, values, and ethical standards and demonstrate the behavioral and service expectations as defined in our policies and procedures.
    • An Associate degree in a related field including, but not limited to, health information, business, healthcare finance required or 5years' experience from which comparable knowledge and abilities have been acquired.
    • Applicant must have 3years of comprehensive billing and denial experience working with commercial and government payer types for both professional and facility claims.
    • Advanced experience with Microsoft office products and ability to accurately manipulate and analyze data independently.
    • Strong understanding of policies, procedures, contractual language and compliance regulations for hospital and professional Services.
    • Strong interpersonal skills, critical thinking skills, independency, and ability to communicate and educate effectively in formal presentation format to all levels of the organization.
    • Driven to learn and able to gain knowledge of various departmental processes to determine root cause analysis that result in overall improvements across the organization.
    • Individual must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served on his/her assigned unit/department. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient status.Must be able to interpret the appropriate information needed to identify each patient's requirements relative to their age-specific needs and to provide the care needed as described in the area's policies and procedures.
      • CPC certification
      • Comprehensive understanding of medical terminology, including CPT-4, ICD-10, diagnosis and procedures coding, and HCPCS coding.

        This position requires a full range of body motion with intermittent bending, squatting, kneeling, and twisting. The associate must be able to sit for three hours, walk for one hour and stand for two hours per day. The associate must be able to lift 20 pounds. The individual must have excellent eye/hand coordination to operate the machines. This position requires corrected vision and hearing in the normal range.

Keywords: Blanchard Valley Health System, Toledo , PFS Claims Management Analyst - 40 hrs/wk., Human Resources , Findlay, Ohio

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