Job Description

#LI-Remote

Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families.

All employees are eligible for medical coverage on their first day! In addition, upon hire all employees are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more! Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law.

The Professional Billing Specialist is responsible for managing all professional billing requirements and managing accounts receivable tasks according to standard and productivity measurements. Responsible to ensure all regulatory and payor guidelines are followed.

Responsibilities

• Coordinating payor denial and appeal follow up activities to ensure timely response from third party payors and the processing of all payor denials, documentation requests and appeals
• Review all denial accounts for categorization, level of appeal, special requirements for initiating appeals
• Communicate global payer issues with the payer relations team.
• Communicating and coordinating with various individuals/distributions and assisting with monitoring of the day-to-day activities related to appeal follow up and denials.
• Maintaining the healthcare tracking tool/application that stores/communicates all claim edits, review and denial activity. This will include user access management, updates to software, and end-user training to support all follow up activities.
• Monitor all Claim Edit and Denial Management work queues and lists to ensure they are fully resolved.
• Ensure medical records requests are completed and submitted within 48 hours.
• Track all denials on a database to determine outcome. Collecting/analyzing, report status, metrics and trends of activity by different reviews from the tool. Distributing reports on a routine basis to specific distribution group.
• Organizing all data and activity in a retrievable way to ensure timely follow up on appeals to third party payors. Assisting with the coordination of denial and review activities and materials for committee meetings, including analyses, reports, etc.
• Knowledgeable about federal, state and third-party claims processing. Supporting projects and initiatives of the Billing and Denials Management teams. This may include coordinating meetings, conducting research for payor criteria, and preparing documents
• Able to build and maintain relationships with payer representatives

This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned.

Qualifications

Required:

• Epic PB Resolute experience
• 5 years' experience in a Healthcare/Hospital Revenue Cycle Environment including Third Party Collection/AR Receivables
• Healthcare Revenue Cycle revenue management EDI Transaction sets including 837P
• Knowledge of insurance contract rates and terms
• Understanding of Registration and Collections
• Understanding of Government and Managed Care billing, coverage and payment rules Ability to comprehend payor 835 and paper EOB responses
• Understanding of CCI edits, CPT, HCPCS, ICD-10 and Revenue Codes
• Intermediate Excel skills
• Excellent computer skills, especially spreadsheet and database applications.
• Knowledge of managed care patient financial systems and of the specific billing and payment standards utilized for services provided within a hospital setting.
• Thorough understanding of managed care payment methodologies and the principles of managed care.
• Certification in Epic PB Resolute - or agree to obtain certification within 12 months after hire
• Bachelor’s Degree or equivalent combination of education and experience

Preferred:

• Knowledge of SQL or Crystal Reports.
• HFMA’s CRCR credential