Billing Optimization Analyst - Hospital

Job Purpose The Billing Optimization Analyst is an experienced hospital billing professional responsible for evaluating and resolving barriers that prevent accurate and timely claim submission. The analyst applies working 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. Working collaboratively with billing, operational, clinical, reimbursement, and technology teams, the analyst shares findings and practical recommendations that improve first-pass clean-claim performance, reduce DNFB, and accelerate revenue capture. Duties & Responsibilities Support the hospital claim-generation lifecycle, from final coding and charge capture through claim creation, validation, and transmissionResearch and resolve billing edits, claim splits, bill holds, rejections, late charges, stop bills, and other exceptions that delay claims from being releasedApply Medicare, Medicaid, managed care, and commercial payer billing requirements to support accurate and timely claim submissionAnalyze recurring claim barriers and help identify root causes across processes, system configuration, payer rules, and upstream workflowsCollaborate with billing leaders and team members to review billing scenarios, share findings, and recommend practical resolution stepsPartner with operational, clinical, reimbursement, coding, IT, and vendor teams to support improvements to edits, work queues, workflows, and escalation processesMonitor first-pass clean-claim rate, bill-hold days, DNFB, rejection trends, and billing throughput to identify improvement opportunitiesDocument billing scenarios, root causes, recommended actions, and reusable guidance to support team consistency Qualifications 2–3 years of hospital billing experience, including hands-on experience resolving claims before submissionWorking 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 claimsKnowledge of Medicare, Medicaid, managed care, and commercial payer billing rules, claim formats, and submission requirementsFamiliarity with UB-04 and 837I requirements, revenue codes, bill types, condition and occurrence codes, modifiers, claim frequency codes, and payer-specific editsAbility to research why a claim cannot be released, identify the appropriate resolution or escalation path, and clearly explain the next action to team members and stakeholdersProficiency in Excel and comfort reviewing billing, edit, hold, and rejection data for trendsClear written and verbal communication skills with a collaborative, consultative approach to problem-solvingExperience researching claim-generation issues in Epic Resolute or a comparable patient accounting systemExperience using clearinghouse tools, payer portals, claim scrubbers, and reporting toolsExposure to multiple hospitals, facilities, or payer environmentsExperience sharing billing guidance or helping team members work through claim issuesApplies hands-on billing knowledge to identify, investigate, and resolve claim edits, splits, holds, rejections, and submission barriersDemonstrates working knowledge of Medicare, Medicaid, managed care, and commercial payer requirements and proactively seeks guidance when neededUses analytical thinking to evaluate billing data and claim-level details, identify patterns and root causes, and recommend practical next stepsBuilds effective partnerships by listening, asking targeted questions, communicating findings clearly, and collaborating with stakeholders on solutionsCollaborates effectively with clinical, operational, financial, reimbursement, coding, and technology teams to support revenue cycle improvement initiativesTakes ownership of assigned issues by driving resolution or appropriate escalation while maintaining accurate and complete documentation Working Conditions Must 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 follow directions, collaborate with others, and handle stressWork Environment: The noise level in the work environment is usually minimal Med-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.