Senior Billing Specialist (Commercial) in Clifton, New Jersey at Progressive Spine and Orthopaedics LLC

JOB TITLE: Senior Billing Specialist (Commercial)
COMPANY: Progressive Billing
PAY Range: OPM Pay Grade 9 (Hourly)
FLSA Status: Non-Exempt

SUMMARY: The Senior Commercial Billing Specialist serves as an advanced subject matter expert responsible for resolving highly complex commercial and out-of-network billing issues, managing escalated payer disputes, and driving reimbursement recovery initiatives. This role provides technical leadership to billing staff, assists with departmental training, and supports management through reporting, process improvement, and quality assurance activities.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
Advanced Commercial Billing & Collections
Manage the department's most complex commercial and OON accounts.
Resolve high-dollar reimbursement disputes and escalated payer issues.
Monitor aging accounts and develop recovery strategies for difficult claims.
Review payment variances and identify underpayment trends.

Denials, Appeals & Escalations
Develop advanced appeal strategies for complex denials.
Coordinate peer reviews, reconsiderations, and external review requests when applicable.
Serve as an escalation resource for staff encountering payer challenges.
Research regulatory, contractual, and reimbursement issues impacting collections.

Negotiation Oversight
Review third-party negotiation activity and outcomes.
Monitor settlement agreements and reimbursement compliance.
Collaborate with negotiators regarding documentation and claim support.
Track performance metrics related to negotiated claims.

Quality Assurance & Auditing
Perform account audits to ensure billing accuracy and compliance.
Review staff work for quality, consistency, and adherence to procedures.
Identify process gaps and recommend corrective actions.
Assist with internal and external audits.

Training & Leadership Support
Mentor Commercial Billing Representatives and Specialists.
Assist leadership with onboarding and training programs.
Develop training materials and reference tools.
Support implementation of new payer requirements and workflow changes.

Reporting & Process Improvement
Prepare reports on denials, appeals success rates, collections performance, and reimbursement trends.
Analyze revenue cycle data to identify improvement opportunities.
Participate in departmental projects and process enhancement initiatives.
Assist leadership in developing operational best practices.

QUALIFICATIONS
High school diploma or equivalent required.
Associate or Bachelor's degree preferred.
Minimum 5 years of commercial medical billing experience.
Extensive experience with out-of-network reimbursement and appeals.
Surgical specialty billing experience strongly preferred.
Expert knowledge of commercial billing and reimbursement processes.
Advanced understanding of payer policies and denial management.
Strong analytical, organizational, and communication skills.
Experience performing audits and quality assurance reviews.
Advanced proficiency with billing systems and reporting tools.

PHYSICAL DEMANDS AND WORK ENVIRONMENT
This position functions in a standard office setting requiring prolonged periods of sitting, computer use, and telephone communication. Additional hours may be necessary during peak operational periods.

DOL / FLSA CLASSIFICATION JUSTIFICATION
Based on an evaluation of the duties performed, the Senior Commercial Billing Specialist is classified as non-exempt under the Fair Labor Standards Act and applicable state wage and hour laws. The primary responsibilities involve advanced billing, collections, appeals, reimbursement analysis, quality review, and technical support functions. Although the position provides mentorship, training assistance, and technical guidance to team members, it does not possess authority over hiring, firing, discipline, compensation decisions, or other management functions.

The role primarily performs specialized operational work directly related to revenue cycle activities rather than management of the business itself. As such, the position does not satisfy the requirements for exemption under the Executive, Administrative, or Professional classifications and remains eligible for overtime compensation.