The Billing Specialist Representative is responsible for securing timely and accurate reimbursement by resolving billing issues with commercial and government payers. This role requires strong critical thinking and analytical skills to identify denial trends, address payment variances, and pursue appropriate corrective actions. Success in this role depends on a proactive, problem-solving mindset and the ability to adapt in a fast-paced, evolving environment.

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Billing & Follow-Up

• Submit timely and accurate claims (UB-04/CMS-1500) to payers, ensuring compliance with regulatory and payer-specific requirements.
• Work claim edits and correct errors in demographic, insurance, and charge data to ensure clean claim submission.
• Conduct prompt and thorough follow-up on outstanding receivables, including appeals and disputes for denials and underpayments.
• Identify and resolve payer overpayments in a timely manner to ensure regulatory compliance and prevent future recoupments.
• Analyze denial reasons and payment variances to identify root causes and recommend process improvements.
• Maintain in-depth knowledge of payer guidelines and federal/state regulations.
• Collaborate with payers and internal departments to resolve issues and achieve account resolution.
• Accurately document all actions and communications in the billing system.

Audit & Analysis

• Review patient accounts for accuracy in demographics, insurance coverage, and billing details.
• Identify patterns or trends in denials and reimbursement discrepancies.
• Assist leadership in developing denial prevention strategies and performance improvement initiatives.
• Prioritize and escalate high-risk accounts for timely resolution.
• Demonstrate initiative in recommending improvements to workflow and system efficiency.

Compliance & Communication

• Maintain compliance with HIPAA and all applicable billing regulations.
• Respond to payer communications via phone, portal, and email in a professional and timely manner.
• Collaborate across teams to ensure coordinated resolution of account issues.
• Communicate effectively with patients, coworkers, and external partners, always maintaining professionalism and respect.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Completing other job-related assignments and special projects as directed.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Education and Experience

Associate’s or Bachelor’s degree in a healthcare or related field preferred. 2+ years of experience in insurance billing and follow-up, with knowledge of UB-04/CMS-1500 claim forms.

Knowledge & Skills

• Strong analytical, problem-solving, and organizational skills.
• Effective written and verbal communication abilities.
• Ability to prioritize, manage multiple tasks, and meet deadlines.
• Proficient with Microsoft 365 (Word, Excel, Outlook); experience with patient accounting systems preferred.
• Demonstrated ability to think critically and adapt to changing environments.

Working Conditions:

• Extended periods of sitting and computer use.
• Must be flexible to work additional hours or shifts as needed.

Physical Demands

• Occasional lifting of storage boxes weighing up to 50 pounds when filled with completed forms.