Reports To: Revenue Cycle Director
FLSA Classification: Full-Time, Non-exempt, Hourly $26.22-$35.51
Senior Medical Claims and Accounts Receivable Analyst
onsite or remote
The ideal candidate will have advanced knowledge of medical coding, billing, insurance reimbursement, payer requirements, and claims processes. A professional certification in medical coding and/or billing is strongly preferred. This individual must be highly analytical, detail-oriented, persistent, and capable of independently researching and resolving complex claims issues.
Key Responsibilities
Accounts Receivable Management
- Manage and actively monitor assigned AR to ensure timely and accurate reimbursement.
- Analyze aging reports and prioritize accounts based on dollar value, age, payer, denial reason, and likelihood of recovery.
- Develop and execute effective strategies to reduce outstanding AR and prevent accounts from becoming significantly aged.
- Identify trends in unpaid, underpaid, and delayed claims.
- Maintain accurate documentation of collection activities, claim status, follow-up efforts, and payer communications.
- Escalate high-dollar, complex, or unresolved accounts appropriately.
Claims Analysis & Denial Resolution
- Conduct detailed reviews of rejected, denied, and underpaid medical claims to determine the root cause of nonpayment.
- Research payer policies, contracts, medical necessity requirements, coding guidelines, authorization requirements, and claim submission rules.
- Determine whether issues are related to coding, billing, authorization, eligibility, documentation, bundling, medical necessity, timely filing, payer processing, or other reimbursement requirements.
- Prepare and submit corrected claims, reconsiderations, appeals, and supporting documentation as appropriate.
- Follow claims through the resolution process and ensure appropriate payment is received.
- Identify recurring denial patterns and recommend corrective action to prevent future denials.
Payment Issue Resolution
- Investigate ongoing payment discrepancies, including underpayments, incorrect contractual adjustments, partial payments, and unexplained nonpayment.
- Compare payer payments against expected reimbursement and contractual terms.
- Identify systematic payer or internal billing issues that may be negatively affecting revenue.
- Work with billing, coding, clinical, administrative, and payer teams to resolve complex reimbursement problems.
- Escalate persistent payer issues when appropriate and maintain detailed records of resolution efforts.
Coding & Billing Review
- Apply knowledge of ICD-10-CM, CPT, HCPCS, modifiers, NCCI edits, payer-specific requirements, and general coding/billing principles when analyzing claims.
- Review claims for potential coding or billing errors contributing to denials or payment delays.
- Collaborate with certified coders, billers, providers, and other revenue cycle personnel when additional expertise or documentation is required.
- Identify opportunities to improve claim accuracy and first-pass payment rates.
Reporting & Process Improvement
- Monitor key AR and claims metrics, including aging, denial rates, recovery rates, payment turnaround, and outstanding balances.
- Analyze trends and prepare reports identifying significant reimbursement problems.
- Recommend process improvements designed to increase collections, reduce denials, and improve cash flow.
- Assist in developing and maintaining denial-management and AR workflows.
- Identify opportunities for automation, workflow improvement, payer escalation, and staff education.
- Provide feedback to leadership regarding recurring payer, coding, billing, and reimbursement issues.
Required Qualifications
- Advanced experience in medical claims, billing, accounts receivable, or revenue cycle management.
- Strong understanding of the healthcare reimbursement and claims process.
- Demonstrated experience researching and resolving complex medical claim denials and payment issues.
- Strong knowledge of insurance payer processes and requirements.
- Excellent analytical, organizational, and problem-solving skills.
- Ability to manage a high-volume AR workload while maintaining accuracy and thorough documentation.
- Strong written and verbal communication skills.
- Ability to independently research problems and follow issues through to resolution.
- Proficiency with electronic medical records (EMR), practice management, billing, claims, and payer systems.
Preferred Qualifications
- Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Biller (CPB), or comparable certification.
- Formal education or training in medical coding, medical billing, health information management, or revenue cycle management.
- Experience with complex specialty claims or high-dollar accounts.
- Experience with payer appeals, reconsiderations, and formal denial processes.
- Experience analyzing contractual reimbursement and payment variances.
- Experience working with Medicare, Medicaid, commercial insurance, and/or other third-party payers.
Skills and Expectations
- Kind and professional demeanor.
- Professional and well-groomed appearance at all times.
- Communicate positively and effectively, both written and verbally, with patients, family, and staff.
- Demonstrate effective organizational skills in an evolving environment.
- Work with honesty, compassion and integrity at all times.
- Understand and adhere to the scope of service for the department and this position.
- Understand and adhere to all of PMC’s policies and procedures.
- Understand and adhere to PMC’s Code of Conduct.
- Adhere to the strictest confidentiality and HIPAA regulations.
- Demonstrate a commitment to building and sustaining a diverse, inclusive, and equitable working environment.
- Ability to remain calm and efficient in emergency situations.
- Demonstrate strong problem-solving skills.
- Demonstrate strong emotional intelligence.
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing this job, the employee:
- Must be able to remain in a stationary position 50% of the time.
- Must be able to move and traverse about the facility 50% of the time.
- Frequently transport objects weighing up to 50lbs
- Occasionally position objects weighing up to 100lbs.
- Must be able to communicate and exchange information in a way others will understand.
- Must be able to recognize details such as color and depth within a few feet of the observer.
- Frequently operates computers, machinery, and other healthcare equipment.
- Constantly positions self to complete essential functions.
- May be required to wear N95s or PAPRs throughout the shift.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Pioneers Medical Center is committed to diversity inclusion, equal treatment, and opportunity in all aspects of recruitment, selection, and employment without regard to race, color, religion, national origin, ethnicity, age, sex, marital status, physical or mental disability, gender identity, sexual orientation, veteran or military status, or any other category protected under the law. As an equal opportunity employer, Pioneers Medical Center will not limit or segregate employees in any way which would tend to deprive them of employment opportunities/promotions, or affect the status of their employment because of race, creed, color, sex, sexual orientation, gender identity, gender expression, marital status, national origin, age, disability, ancestry, or veteran status.
