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Patient Financial Services

Denials & Refund Specialist - Full Time - 10/17/18

Bargaining Unit:  Non Licensed                        Rate of Pay:  $24.70 / HR + DOE

SUMMARY:   Analyzes denials and credit balances for determination of appeal possibilities, refund, or adjustment to the patient’s account.  Determines what will be necessary to secure the missing payment and/or address the credit on the patients account.  Processes statements in legacy systems until no longer necessary.  Provides reporting from multiple systems for multiple clients. Works on EPIC and/or other systems to identify back up and documentation that can be used to appeal and/or to support resolution of credit balances.


Identifies refunds utilizing all tools and department systems available.

Researches denied accounts based on rejection (Claims Adjustment Reason Codes -CARC) presented on 3rd party payer remittance advices. 

Sorts denials based on resolution requirements.

Generates denial letters and/or web-portal requests for reconsideration and/or appeals.

Works with appropriate clinical staff to secure documentation and generate appeal requests, if denial requires additional clinical documentation,

Researches and resolves all credits on patient accounts by determining if balance is an error such as incorrect contractual allowance, or a true balance due to some party.

Generates refunds when valid payer requests are received with back up and documentation.

Processes both patient and third party payer refunds on patient accounts accurately and on a timely basis.

Generates and sends patient refunds within thirty (30) days of the overpayment.

Completes processing of refunds through the hospital information systems.

Recalculates initial contractual posted adjustment and corrects errors made to a patient’s account.

Compiles a log with the originating cause of the refund, and reports recurring issues to management.

Runs ad hoc and scheduled reports for management and for outside services, including but not limited to quarterly Medicare credit balance report for all entities and HELP Financial updates.

Runs accurate patient statements from legacy systems weekly, or as required.

Processes weekly and month-end closing for legacy systems until no longer necessary per management.

Assists with on-site credit balance reviews by payers and in-house auditors.

Posts charges and/or adjustments to all systems as needed including post-audit adjustments.

Researches and resolves unapplied payments in the undistributed account.

Documents all activities via mail, e-mail, telephone, written correspondence or in person into the patient’s account.

Cross-trains in other related business office functions to ensure smooth operation of the department.

Communicates with the finance department, as necessary regarding General Ledger accounts to resolve all cash-related issues.

Provides back-up coverage for the front desk for breaks, lunches and other times as required.

Opens, organizes and distributes the mail independently.

Maintains confidentiality of all protected health information (PHI).

Other duties as may be assigned.

Demonstrates System Values in performance and behavior.

Complies with System policies and procedures.

EDUCATION AND EXPERIENCE:  High school diploma or general education degree (GED).  Minimum of 2 to 3 years’ experience working Hospital or Physician Accounts Receivable with understanding of payer reimbursement rules including how to calculate correct payment and contractual allowances.  Preferred:  EPIC System with Hospital Billing and/or Physician Billing preferred. 

OTHER EXPERIENCE/QUALIFICATIONS: Preferred two years in health care financial related experience.  This position requires detailed analysis and critical thinking.