Billing Optimization Analyst

Billing Optimization AnalystThe Billing Optimization Analyst is the subject matter expert accountable for identifying and permanently resolving the barriers that prevent accurate and timely claim submission. Applying expert knowledge of Medicare, Medicaid, managed care, and commercial payer requirements across the claim-generation lifecycle, including edits, claim splits, bill holds, rejections, late charges, and other exceptions, the Billing Optimization Analyst exercises independent judgment to diagnose root causes, works with billing, IT, and operational teams to implement fixes, and ensures issues do not recur.Duties & ResponsibilitiesServe as the subject matter expert for the hospital claim-generation lifecycle, from final coding and charge capture through claim creation, validation, and transmissionResearch and resolve complex billing edits, claim splits, bill holds, rejections, late charges, stop bills, and other exceptions that delay claims from being releasedInterpret and apply Medicare, Medicaid, managed care, and commercial payer billing requirements to determine the correct billing approach for complex or non-standard scenariosAnalyze recurring claim barriers and determine root causes across processes, system configuration, payer rules, and upstream workflowsLead working sessions with billing leaders and team members to review billing scenarios, present findings, and agree on resolution steps and ownersPartner with operational, clinical, reimbursement, coding, IT, and vendor teams to design and drive improvements to edits, work queues, workflows, and escalation processesMonitor first-pass clean-claim rate, bill-hold days, DNFB, rejection trends, and billing throughput to confirm implemented improvements are sustained, identify new improvement opportunities, and coordinate additional follow-up when results do not meet established performance targetsDevelop billing guidance, standard work, and education based on root-cause findings to prevent recurrence and drive team consistencyAdvise billing and client leadership on billing risks, priorities, and the financial impact of recommended changesOther duties as assignedUse, protect and disclose patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standardsUnderstand and comply with Information Security and HIPAA policies and procedures at all timesLimit viewing of PHI to the absolute minimum as necessary to perform assigned dutiesQualificationsBachelor's degree in healthcare administration, business, finance, or a related field; an equivalent combination of education and progressive hospital billing experience will be considered4+ years of progressive hospital billing experience, including hands-on resolution of complex claims before submission and leading the resolution of recurring billing issuesAdvanced knowledge of the end-to-end institutional claim lifecycle, including claim edits, split-billing scenarios, bill holds, rejections, late charges, stop bills, and corrected or replacement claimsIn-depth knowledge of Medicare, Medicaid, managed care, and commercial payer billing rules, claim formats, and submission requirementsStrong working knowledge of UB-04 and 837I requirements, revenue codes, bill types, condition and occurrence codes, modifiers, claim frequency codes, and payer-specific editsDemonstrated ability to identify root causes, lead cross-functional teams through performance improvement initiatives, and sustain results while working with a high degree of independenceAbility to analyze billing, edit, hold, and rejection data to identify trends and quantify financial impactExperience researching claim-generation issues in Epic Resolute or a comparable patient accounting system preferredExperience using clearinghouse tools, payer portals, claim scrubbers, and reporting tools preferredExposure to multiple hospitals, facilities, or payer environments preferredProficiency in Microsoft Office SuiteStrong interpersonal and influencing skills, with the ability to communicate and present findings at all levels of the organization, including executive leadershipStrong problem solving and creative skills and the ability to exercise independent judgment and make decisions based on accurate and timely analysesHigh level of integrity and dependability with a strong sense of urgency and results orientedExcellent written and verbal communication skills requiredWorking ConditionsOccasional travel to client facility sites may be requiredAbility to work outside of normal business hours to support special projectsMust possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposesPhysical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hearMental Demands: The employee must be able to exercise independent judgment, collaborate with others, and manage competing priorities and changing business needsWork Environment: The noise level in the work environment is usually minimalMed-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.