Billing QA Specialist

This is an on-site position with the possibility of turning into a hybrid position once Meditech system is live.

PURPOSE STATEMENT

The Billing QA Specialist is responsible for ensuring clean, accurate claims are released prior to submission to minimize denials and rework. This role serves as a quality checkpoint in the revenue cycle, working within Meditech work queues to resolve claim edits, validate coding and billing compliance, and support overall revenue integrity. The Billing QA Specialist plays a critical role in reducing denials, improving cash flow, and achieving a >90% clean claim rate.

ESSENTIAL FUNCTIONS

Claim Edit Resolution (Primary Function)

• Work MEDITECH claim edit work queues.
• Resolve hard and soft claim edits prior to billing.
• Review and Correct:
• Missing/invalid modifiers
• CPT/HCPC and ICD-10 inconsistencies
• NCCI edits and bundling issues
• Authorization requirements
• payer-specific billing rules
• Ensure all required documentation and coding elements are present before claim release.

Pre-Bill Quality Assurance

• Perform detailed review of high-dollar and high-risk claims.
• Validate:
• Accurate payer selection
• Correct billing entity (facility & professional)
• Charge integrity and completeness
• Prevent claims from being submitted with known errors.

Denial Prevention and Trend Identification

• Analyze common claim edit failures and denial trends.
• Partner with:
• Patient Access (eligibility/auth issues)
• Coding (coding accuracy and documentation)
• Billing (workflow/process issues)
• Provide feedback to reduce repeat errors.

Collaboration and Escalation

• Collaborate with:
• Coders
• Denial Specialists
• A/R Team
• Escalate complex or recurring issues to leadership.
• Participate in workflow improvement initiatives.

Productivity and Compliance

• Meet daily productivity targets for claim review and resolution.
• Maintain compliance with:
• CMS guidelines
• Payer billing requirements
• Organizational policies

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

• High school diploma or equivalent.
• An Associate's degree in Business-related field is required.
• Must possess a minimum of 3+ (three) years of healthcare billing, revenue cycle, or claims experience.
• Certification required or obtained within one year of employment (one or more of the following):
• CPC (Certified Professional Coder)
• CPB (Certified Professional Biller)
• CRCR (Certified Revenue Cycle Representative)
• Experience working in an HER system (MEDITECH preferred).
• Experience working in a claim scrubber (SSI preferred).
• Strong understanding of:
• CPT, HCPCS, ICD-10 coding basics
• Claim edit and payer rules
• Insurance billing workflows
• Familiarity with denial management and A/R follow-up.

Key Competencies

• Strong attention to detail.
• Analytical/problem-solving skills.
• Ability to identify root causes of billing errors.
• Effective communication across departments.
• Ability to manage high work volumes in a deadline-driven environment.
• Performance Metrics
• Clean claim rate (90%).
• Claim edit turnaround time (24 hours).
• Reduction in denial rates tied to preventable errors.
• Work queue aging and volume management.

PHYSICAL/MENTAL REQUIREMENTS

• Must be able to sit and stand, intermittent 8 to 10 hours a day.
• Must be able to use standard office equipment, including the telephone and computer keyboard.
• Continuously works under pressure of near 100% accuracy while meeting inflexible deadlines.
• Continuously utilizes manual/bi-manual dexterity, near vision, speech, and hearing.
• Frequently stands, walks, sits and utilizes eye/hand coordination and color definition.
• Occasionally reaches above shoulder, regularly required to lift and/or carry up to 40 lbs.
• Occasionally walks on uneven surfaces.