Billing Problem Resolution Specialist

Job Description

Job Description

Full-Time Hybrid position | On site in Santa Ana CA 50% of weekly hours | M - F 7:30 a.m. - 4:30 p.m.
Position Summary

The Billing Problem Resolution Specialist is responsible for investigating, resolving, and preventing billing issues related to laboratory testing services. This role serves as a key liaison between patients, clients, health plans, laboratories, providers, and internal departments to ensure accurate billing, timely reimbursement, and exceptional customer service. The specialist analyzes complex billing discrepancies, researches insurance denials, resolves claim issues, and identifies opportunities to improve billing processes and reduce revenue leakage.

Essential Duties and Responsibilities

• Investigate and resolve laboratory testing billing discrepancies, claim denials, payment variances, and customer inquiries.
• Research payer policies, coverage determinations, coding requirements, and reimbursement issues affecting laboratory claims.
• Review patient accounts to identify and correct demographic, insurance, coding, or charge-related errors.
• Communicate with insurance carriers, healthcare providers, clients, and patients to obtain information necessary to resolve billing concerns.
• Analyze explanation of benefits (EOBs), remittance advice, denial codes, and payer correspondence.
• Prepare and submit corrected claims, appeals, reconsiderations, and supporting documentation as needed.
• Monitor aging accounts and unresolved billing issues to ensure timely follow-up and resolution.
• Collaborate with laboratory operations, accessioning, client services, compliance, and finance teams to resolve systemic issues.
• Maintain detailed documentation of all account activity and resolution efforts within billing systems.
• Identify recurring billing issues and recommend process improvements to enhance reimbursement and customer satisfaction.
• Assist in the development and maintenance of billing procedures, training materials, and workflow documentation.
• Ensure compliance with federal and state regulations, HIPAA requirements, payer guidelines, and company policies.
• Participate in special projects related to revenue cycle optimization and billing performance improvement.

QualificationsRequired

• High school diploma or equivalent.
• Minimum of two (2) years of experience in healthcare billing, medical claims processing, revenue cycle management, or insurance collections.
• Knowledge of medical terminology, insurance billing processes, and healthcare reimbursement methodologies.
• Experience researching and resolving claim denials and billing discrepancies.
• Strong analytical and problem-solving skills.
• Excellent verbal and written communication skills.
• Proficiency with Microsoft Office applications, particularly Excel.
• Ability to prioritize workload, manage multiple cases, and meet deadlines.

Preferred

• Associate's or Bachelor's degree in Healthcare Administration, Business, Finance, or related field.
• Experience with clinical laboratory or diagnostic testing billing.
• Knowledge of CPT, ICD-10, HCPCS, and laboratory coding requirements.
• Experience working with Medicare, Medicaid, commercial insurers, and managed care organizations.
• Familiarity with electronic health records (EHR), laboratory information systems (LIS), and billing software.

Knowledge, Skills, and Abilities

• Strong investigative and critical-thinking capabilities.
• Ability to interpret insurance policies, reimbursement guidelines, and contractual requirements.
• Exceptional customer service orientation and conflict-resolution skills.
• Ability to handle sensitive and confidential information appropriately.
• Strong attention to detail and accuracy.
• Ability to work independently while collaborating effectively across departments.
• Demonstrated ability to identify trends and recommend operational improvements.

Working Conditions

• Primarily office-based environment with extensive computer use.
• Frequent interaction with patients, clients, insurance representatives, and internal stakeholders.
• May require occasional overtime to meet department deadlines or resolve high-priority issues.

Performance Expectations

Success in this role will be measured by:

• Timely resolution of billing issues and customer concerns.
• Reduction in claim denials and rebilling rates.
• Accurate documentation and account maintenance.
• Achievement of productivity and quality standards.
• Positive customer and client satisfaction outcomes.
• Contribution to revenue cycle improvement initiatives.

This job description is intended to describe the general nature and level of work being performed by individuals assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, and qualifications required. Management reserves the right to modify, add, or remove duties and responsibilities as business needs dictate.