Overview
This role involves processing, auditing, and submitting primary and secondary insurance claims to ensure accuracy, compliance, and timely reimbursement. The specialist will use electronic claims management systems to review, correct, and resolve billing errors, denials, and rejections. Collaboration with internal teams, facility liaisons, and payers is essential to maintain clean claim submission and adherence to federal, state, and payer-specific regulations.
Responsibilities
- Process and submit primary and secondary insurance claims accurately and timely, following payer guidelines and regulatory requirements.
- Review and resolve claim errors, rejections, and denials; make necessary corrections and resubmit claims.
- Demonstrate working knowledge of billing forms such as UB-04, CMS-1500, or state-specific forms, ensuring appropriate documentation.
- Audit claims for accuracy, checking for duplicate charges, overlapped accounts, and missing information before submission.
- Conduct payment research with insurance payers via phone, meeting required metrics and KPIs.
- Investigate and process rebill requests, verifying claim accuracy and updating as directed by facility or coding liaisons.
- Maintain up-to-date knowledge of billing regulations, payer policies, and electronic submission guidelines.
- Utilize electronic billing systems to analyze, research, and transmit claims, documenting actions in the collection system.
- Monitor and report charging or edit trends; collaborate with coding, patient access, and ancillary departments to improve billing accuracy.
- Perform daily balancing tasks using SSI and other billing systems; escalate unresolved issues or delays to the Billing Services Manager.
- Communicate professionally with payers, facility representatives, and internal teams to ensure efficient issue resolution and follow-up on outstanding claims.
- Maintain regular and reliable attendance.
- Comply with all organizational policies and standards.
- Perform other duties as assigned.
Qualifications
- High School Diploma or GED required.
- Associate Degree in Business, Healthcare Administration, Medical Billing, or related field preferred.
- 0-1 years of experience in medical billing, insurance claims processing, or revenue cycle operations required.
- 1-3 years of billing experience in a medical facility, ambulatory surgery facility, or acute-care setting preferred.
- Experience with hospital or physician billing, including knowledge of payer policies and electronic claims systems preferred.
Knowledge, Skills, and Abilities
- Basic understanding of insurance claim processing, medical billing, and reimbursement guidelines.
- Familiarity with billing software and electronic claims management systems (e.g., SSI, Pulse/DAR) and eligibility tools.
- Knowledge of CMS, Medicaid, Medicare, and commercial insurance billing regulations.
- Ability to analyze and resolve claim errors, denials, and rejections efficiently.
- Strong attention to detail, organizational skills, and ability to meet deadlines.
- Proficiency in Microsoft Office Suite (Excel, Outlook, Word) and electronic health record (EHR) systems.
- Excellent communication and problem-solving skills; ability to interact professionally with internal teams and external payers.
Licenses and Certifications
- CPB (Certified Professional Biller) certification preferred.
Compensation and Benefits
- Comprehensive health coverage including medical, dental, and vision plans.
- Competitive salary and full benefits package.
- Paid time off.
- Flexible scheduling.
- 401(k) plan with matching contributions.
Location
This position supports healthcare delivery systems operating across multiple markets and states, including hospitals, physician practices, urgent care centers, freestanding emergency departments, imaging centers, cancer centers, and ambulatory surgery centers.