Billing QA Specialist

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

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

• Educational Requirements
• High school diploma or equivalent.
• An Associate's degree in Business-related field is required.
• Experience Requirements
• 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)
• Technical Requirements
• 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

• Attention to Detail
• Problem-Solving Skills
• Root Cause Analysis
• Communication
• Deadline Management

PRODUCTIVITY AND COMPLIANCE

• 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.