Lead Medical Billing Specialist

The Lead Medical Billing Specialist serves as a subject-matter expert and day-to-day operational resource for facility and professional billing and accounts-receivable activities. The position provides frontline guidance to billing associates, coordinates workflow and coverage, supports complex account resolution, and serves as the first escalation point for technical billing and reimbursement questions. Working in partnership with the Billing Supervisor, the lead supports clean-claim performance, timely follow-up, accurate reimbursement, denial prevention, productivity, quality, and regulatory compliance.

Operational portfolios may include UB-04 facility claims, CMS-1500 professional claims, specific payers, financial classes, and may be reassigned as business needs change without changing the position's core duties, qualifications, or classification.

• Duty 1: Answer first-level associate questions, perform billing and payer research, explain findings, and escalation unresolved or high-risk issues to the Billing Supervisor or appropriate subject-matter resource.
• Duty 2: Maintain working knowledge of UB-04 and CMS-1500 billing processes, including claim edits, coding and modifier impacts, revenue codes, place of service, payer-specific requirements, timely filing, corrected claims, and supporting documentation.
• Duty 3: Review complex, high-dollar, aged, underpaid, rejected, denied, or escalated accounts; research payer guidance and recommend correction, appeal, follow-up, or escalation strategies.
• Duty 4: Coordinate with Revenue Integrity analysts to Identify recurring claim edits, billing defects, eligibility or authorization gaps, documentation issues, denial patterns, payer trends, and reimbursement barriers; summarize findings and recommend corrective action.
• Duty 5: Collaborating with Patient Access, Health Information Services, Denials Management, Coding, Case Management, clinical departments, Information Technology, Contracting, payers, and other stakeholders to resolve account and workflow issues.
• Duty 6: Monitor and coordinate daily work queues, unbilled accounts, claim rejections, denial and follow-up inventories, aging, priority balances, productivity indicators, and supervisor-approved work priorities.
• Duty 7: Communicates workflow expectations and supervisor-approved priorities; identify missed deadlines, performance concerns, compliance risks, material reimbursement exposure, or unresolved barriers and promptly elevate them to the Billing Supervisor.
• Duty 8: Assist the Billing Supervisor with daily staffing coverage, payroll, workload balancing, assignment recommendations, backlog-reduction plans, and identification of capacity constraints or risks to deadlines.
• Duty 9: Coordinate onboarding and training needs with the department's educator/trainer; provide workflow-specific mentoring, side-by-side support, job reinforcement, and feedback on recurring knowledge gaps.
• Duty 10: Support quality reviews, system testing, payer or program implementations, policy and procedure updates, special projects, and workflow-improvement initiatives.
• Duty 11
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  Maintain an individual billing and follow-up assignment sufficient to remain current in systems, workflows, claim requirements, and payer policies and to support department production needs. Provide overlapping claims coverage.

• High school diploma or GED equivalent.
• Two (2)+ years of medical billing, claims, reimbursement, denials management, or healthcare accounts receivable experience. Strong knowledge of billing regulations and claim submission processes.
• Working knowledge of both facility and professional claim workflows, including overlapping claims process. Demonstrate ability to develop cross-functional proficiency within 6 months.
• Demonstrated ability to research payer requirements, interpret billing guidance, resolve complex accounts, and communicate conclusions clearly.
• Demonstrated ability to train, mentor, coordinate work, and influence peers without direct supervisory authority.
• CPFSS certification or obtain within 6 months of hire.
• Knowledge of revenue cycle workflows and systems used within the Revenue Cycle such as Cerner, Trisus, Forvis, Quadax, Kai Nexus, 3M, Experian, etc.
• Regulatory compliance and reimbursement of methodologies knowledge required. Ability to research, review, analyze, and interpret Federal, State and Local billing regulations required.
• Ability to compile, analyze and…