SHIFT:
Day (United States of America)
Seeking Breakthrough Makers
Children’s Hospital of Philadelphia (CHOP) offers countless ways to change lives. Our diverse community of more than 20,000 Breakthrough Makers will inspire you to pursue passions, develop expertise, and drive innovation.
At CHOP, your experience is valued; your voice is heard; and your contributions make a difference for patients and families. Join us as we build on our promise to advance pediatric care—and your career.
CHOP does not discriminate on the basis of race, color, sex, national origin, religion, or any other legally protected categories in any employment, training, or vendor decisions or programs. CHOP recognizes the critical importance of a workforce rich in varied backgrounds and experiences and engages in ongoing efforts to achieve that through equally varied and non-discriminatory means.
A Brief Overview
Primarily responsible for timely resolution of low complexity patient accounts. Assigned duties include researching account balances and following up with collection calls to insurers and parents. Reviewing claims with no response. Reviewing denied claims or underpaid claims and resolving the denial and filing appeals, as necessary. Ensuring all information pertaining to collection activity is fully and accurately documented in the patient accounting system. Works to identify payment and denial trends for timely resolution. Works to identify internal and external causes of denials for timely resolution. Ability to work independently or as a member of a project team. This position could be assigned to hospital, professional or home care claims. Supports the CHOP mission with efficient and effective revenue cycle management. For pharmacy accounts, responsibilities also include reviewing pharmacy‑specific denials, researching NDC‑related issues, coordinating with pharmacy operations when claim clarification is needed, and ensuring accurate resolution of high‑volume, low‑dollar pharmacy claims.
Why This Role Is Exciting
High Impact
Play a key role in optimizing pharmacy revenue by reviewing and resolving pharmacy-specific denials, including NDC issues, prior authorization denials, and quantity limit rejections. You’ll directly impact cash flow by ensuring accurate resolution of high-volume, low-dollar claims while maintaining strong productivity and quality standards. Manage complex A/R scenarios, including multi-line claim issues, coordination of benefits, and unique pharmacy billing structures.
Strategic Collaboration
Partner with internal clinical and operational pharmacy teams to resolve claim issues and clarify documentation as needed. Identify payer trends, including underpayments and recurring denial patterns, and escalate systemic issues to drive process improvements that enhance financial performance and operational efficiency.
Growth & Development
CHOP is deeply invested in your growth subject matter expert and leader. Beyond internal leadership development, you will receive a complimentary Healthcare Financial Management Association (HFMA) membership, providing access to nationally recognized certifications and a network of experts at the intersection of finance and technology.
Community & Purpose
Participate in enterprise-wide volunteer opportunities and patient-focused initiatives that allow you to contribute beyond your day-to-day work.
What you will do
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Submits timely, accurate claims to insurance carriers according to insurance payor guidelines through established methods and procedures using current available technology.
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Resolve patient insurance balances by analyzing denials and using critical thinking skills and knowledge of payer requirements to determine the steps needed to obtain payment. Work in either No Pay No Response, Denial work queues, or both.
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Based on payer processes, utilize payer portals, paper/electronic remits and/or place calls to the payer to understand and resolve denials.
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Perform adjustments as needed.
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Ability to manage daily job functions along with special project work and prioritize level of importance on demand.
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Identifying third party payor response trending and escalation to management team as deemed necessary.
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Reviewing data sets CPT-codes, IDC-10 codes, HCPCS codes, coordination of benefits, registration discrepancies, third party payer rules, and payer contracts.
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Prioritize assigned work based on department needs and direction from leadership team.
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Follow workflows to route accounts to other CHOP departments (Case Management, Medical Records, Credit Resolution, Billing, Abstraction, Clinical Teams, Coding etc.) to address denials.
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Advise supervisor of contractual issues as discovered.
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Place phone calls, sends email or written communication to families to resolve denials that require intervention from the guarantor.
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Document each account thoroughly, explaining action taken on the account and completing note template provided.
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Gather Medical Records, using ROI, to assist in resolving denials as needed.
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Files appeals on behalf of the patient to resolve denials. Reviews and acts on correspondence for assigned accounts.
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Position requires adherence to production and quality metrics.
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Identifies trends in assigned work queues and reports to leadership.
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Works accounts holistically, building on the last intervention and not repeating tasks.
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Identifies patients with multiple denials and works from a guarantor level to resolve issues completely for a family.
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Completes projects as assigned for specific payers or specific types of accounts, ensuring deadlines are met.
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Excellent oral and written communication skills with strong analytical skills.
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Suggests ideas and solutions for performance and quality improvement and provides feedback to team leaders.
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Responsible for full comprehension of CHOP revenue cycle work design including registration, billing, payment posting, account receivable follow-up, and compliance actions.
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Demonstrates quality and effectiveness in work habits in every interaction with colleagues and leadership.
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Provides training as assigned to new employees, as well as cross training.
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Interfaces well with all levels of staff and management.
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Meets established daily/weekly reasonable work expectation of productivity and quality requirements.
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Maintains all PHI in accordance with HIPPA, JACHO, third party contractual agreements along with CHOP policy and procedures.
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Demonstrates behaviors that are consistent with CHOP’s organizational values of Integrity, Compassion, Accountability, Respect and Excellence (ICARE). Ensures work is performed, relationships are built, responsibility is assumed, and service delivered expresses the CHOP’s values through action.
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Ability to communicate effectively and collaborate with teams across Patient Financial Services and other departments around operational efficiencies. Provide recommendations for corrective action to management team to ensure efficiency of the revenue cycle.
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Reports safety hazards, accidents and incidents, and unsafe working conditions promptly.
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Consistently supports compliance by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations.
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Other duties as assigned within the scope of the responsibilities.
Education Qualifications
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High School Diploma / GED - Required
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Bachelor's Degree - Preferred
Experience Qualifications
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At least two (2) years experience in billing, payment posting, operations, or related role - Required
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At least three (3) years experience in billing, payment posting, operations, or related role - Preferred
Skills and Abilities
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HIPAA compliance standards (Required proficiency)
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Effective communication, interpersonal skills, analytical skills, and problem solving skills. (Required proficiency)
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Excellent organizational and time management skills. (Required proficiency)
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Detail and results oriented. (Required proficiency)
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High aptitude for math. (Required proficiency)
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Excellent writing and oral communication skills. (Required proficiency)
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Ability to work independently and prioritize work. (Required proficiency)
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Basic Computer skills (Required proficiency)
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High proficiency in Microsoft Excel. (Required proficiency)
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Demonstrated customer service skills, customer focus abilities and the ability to understand Children’s Hospital of Philadelphia customer needs. (Required proficiency)
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Must maintain high-level knowledge of claim submission requirements. (Required proficiency)
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Ability to work cooperatively in a team environment. (Required proficiency)
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Demonstrated effective interpersonal, verbal, and written communication skills. (Required proficiency)
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Knowledge of Microsoft Office applications including Word, Excel. (Required proficiency)
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Must have 10-key by touch. (Required proficiency)
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Demonstrated experience with multiple computer applications. (Required proficiency)
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Experience in using commonly used electronic health records and healthcare revenue cycle financial management systems. (Required proficiency)
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Knowledge of third-party reimbursement and physician/hospital billing. (Preferred proficiency)
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Experience in using commonly used electronic health records and healthcare revenue cycle financial management systems. (Preferred proficiency)
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Experience with Epic systems (Preferred proficiency)
To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must receive an annual influenza vaccine. Learn more.
EEO / VEVRAA Federal Contractor | Tobacco Statement
SALARY RANGE:
$28.05 - $35.05 Hourly
Salary ranges are shown for full-time jobs. If you're working part-time, your pay will be adjusted accordingly.
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At CHOP, we are committed to fair and transparent pay practices. Factors such as skills and experience could result in an offer above the salary range noted in this job posting. Click here for more information regarding CHOP's Compensation and Benefits.
