PFS Complex Claims Specialist

Iberia Medical Center (IMC) in New Iberia, LA is looking for team members who will help advance our vision to be the premier hospital of choice for patients, physicians and employees. We've been caring for our community for over 60 years and offer many diverse career paths. Our new employees experience opportunities to learn and grow while caring for their families, friends and neighbors.

IMC is currently looking for a PFS Complex Claims Specialist , who ensures Ensures all assigned complex Commercial, Workers' Compensation, VA, Blue Cross, Medicare Advantage, Medicaid, and specialty claims are researched, resolved, appealed, and collected in a timely and accurate manner. Handles complex insurance denials, appeals, payment disputes, refund requests, and overpayment investigations to ensure appropriate reimbursement and timely resolution of outstanding accounts. Monitors assigned billing reports, researches payer policy changes, identifies denial trends, and communicates findings to leadership to improve billing accuracy, reduce denials, and enhance revenue cycle performance.

SCHEDULE

• Full-Time
• Monday through Friday 8:00am- 4:30pm

JOB RELATIONSHIP

• WORKERS SUPERVISED: None
• SUPERVISED BY: PFS Assistant Manager

QUALIFICATIONS:

• Education: High school graduate or equivalent.
• Licensure/Certification: N/A.
• Training and Experience: Minimum 5 years prior medical billing and insurance collections experience, specific to hospitals.

PRINCIPLE TASKS, DUTIES, AND RESPONSIBILITIES:

• Assists current billers with complex denials, billing issues, and special projects as needed.

• Serves as primary backup for Commercial, Workers' Compensation, VA, Blue Cross, Medicare Advantage, SNF, Hospice, Copay Assistance, and Medicaid billing and follow-up.

• Prepares and files assigned 121 claims.

• Handles the preparation, billing, and filing of all inpatient and outpatient psychiatric claims and other specialty accounts as assigned.

• Handles high-level disputes, appeals, and escalations for accounts 120 days or older from discharge date.

• Researches and reviews payer refund and overpayment requests to determine appropriate approval or dispute.

• Researches payer policy changes resulting in denials and reports findings to management.

• Communicates denial trends and identifies opportunities for process improvement to the PFS Supervisor and PFS Lead.

• Works daily billing reports, including Late Charge, Secondary Billing, Exceptions, Unchecked, and 24/72-Hour Reports.

• Ensures assigned denials, refile requests, and other insurance correspondence are addressed within 3-5 business days.

• Performs additional duties and responsibilities as assigned by the supervisor.

IBERIA MEDICAL CENTER is an EEO Employer - M/F/Protected Veteran Status

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