Pre Billing Specialist II

Job Description

Job Description

On-Site/In-Person | Woodland Hills, CA | Full-Time | M-F 8:00 a.m. - 5:00 p.m.

The Pre‑Billing Specialist II is responsible for advanced pre-claim review, validation, and issue resolution to ensure accurate, compliant, and clean claim submission for laboratory services. This role requires strong knowledge of laboratory billing workflows, payer policies, and medical necessity requirements. The position plays a key role in denial prevention by proactively identifying and resolving complex issues related to coding, eligibility, and documentation prior to claim submission.

Key Responsibilities

Advanced Pre-Billing Review & Claim Preparation

• • Perform comprehensive pre-bill review of laboratory claims to ensure accuracy, completeness, and compliance prior to submission
  • Validate complex patient demographics, insurance coverage, and ordering provider information
  • Identify trends and recurring issues impacting claim quality and first-pass acceptance

Medical Necessity & Coding Validation

• • Evaluate diagnosis-to-procedure code alignment using payer-specific guidelines, including Medicare LCD/NCD policies
  • Review and validate CPT/HCPCS coding for laboratory services, including specialty and high-complexity testing
  • Identify potential medical necessity denials and ensure appropriate documentation or ABN workflows are applied

Pre-Bill Edits & Issue Resolution

• • Independently resolve complex claim edits and exceptions within billing systems and clearinghouse tools
  • Research and troubleshoot discrepancies related to eligibility, authorizations, coding, or charge capture
  • Escalate systemic issues and recommend process improvements

Charge Integrity & Revenue Accuracy

• • Review charge capture processes to ensure alignment between performed tests and billed services
  • Support revenue integrity by identifying underbilling, overbilling, or missed charges
  • Partner with coding and compliance teams on billing accuracy and audit readiness

Workflow Optimization & Quality Assurance

• • Monitor and prioritize work queues to meet turnaround time and productivity standards
  • Conduct quality checks and provide feedback to entry-level staff
  • Assist in developing and refining standard operating procedures (SOPs)

Collaboration & Cross-Functional Support

• • Work closely with accessioning, coding, billing, and client services teams to resolve pre-bill issues
  • Serve as a subject matter expert (SME) for pre-billing processes and payer requirements
  • Support training and onboarding of new team members

Required Qualifications

• High school diploma or equivalent (Associate or Bachelor’s degree preferred)
• 2–5+ years of experience in medical billing, revenue cycle, or laboratory billing
• Strong understanding of:
  • CPT/HCPCS and ICD-10 coding
  • Insurance eligibility and coverage rules
  • Medical necessity requirements (especially lab-specific)
• Experience working with billing systems, LIS, EMR, or clearinghouse tools
• Ability to analyze and resolve complex billing issues independently

Preferred Qualifications

• Laboratory billing or diagnostic services experience (e.g., pathology, genetic testing, reference labs)
• Experience with Medicare/Medicaid billing rules and payer-specific policies
• Familiarity with Epic (Beaker), Cerner, or comparable systems
• Certification (preferred but not required):
  • CPC (Certified Professional Coder)
  • CPB (Certified Professional Biller)

Core Competencies

• Advanced analytical and problem-solving skills
• Deep attention to detail and accuracy
• Strong understanding of revenue cycle workflows
• Ability to prioritize in a high-volume environment
• Leadership mindset with mentoring capability