Billing QA Specialist

Western Missouri Medical Center; Warrensburg (MO); On-site; USD 52,000 - 66,000; Full time

Job summary

Western Missouri Medical Center is seeking a Billing QA Specialist to ensure clean, accurate claims before submission. You will work in MEDITECH queues, validate coding and billing compliance, and aim for a 90%+ clean claim rate.

The role emphasizes high accuracy, collaboration across revenue-cycle teams, and improving workflows for denial prevention. The position requires 3+ years in healthcare billing, relevant certifications within a year, and strong attention to detail.

Qualifications

• High school diploma or equivalent.
• Associate’s degree in a business-related field required.
• Minimum of 3+ years of healthcare billing, revenue cycle, or claims experience.
• Certification required or obtained within one year of employment (CPC, CPB, or CRCR).
• Experience working in a 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; Denial management and A/R follow-up.

Responsibilities

• 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.
• 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.
• Analyze common claim edit failures and denial trends.
• Partner with: Patient Access, Coding, Billing; Provide feedback to reduce repeat errors.
• Collaborate with Coders, Denial Specialists, A/R Team; Escalate complex issues; Participate in workflow improvements.
• Meet daily productivity targets for claim review and resolution.
• Maintain compliance with CMS guidelines, payer billing requirements, and organizational policies.

Skills

Attention to detail

Analytical/problem-solving

Cross-functional communication

Deadline-driven

Process improvement

Education

Associate’s degree in a business-related field

High school diploma or equivalent

CPC (Certified Professional Coder)

CPB (Certified Professional Biller)

CRCR (Certified Revenue Cycle Representative)

Job description

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

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

Requirements

Education / Experience / Skill Requirements

• High school diploma or equivalent.
• Associate’s degree in a business‑related field required.
• Minimum of 3+ 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)
• 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
  • Denial management and A/R follow‑up

Key Competencies

• Strong attention to detail.
• Analytical/problem‑solving skills.
• Ability to identify root causes of billing errors.
• Effective communication across departments.
• Ability to manage high work volumes in a deadline‑driven environment.
• Performance metrics:
• 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 work under pressure of near 100% accuracy while meeting inflexible deadlines.
• Continuously utilize manual/bi‑manual dexterity, near vision, speech, and hearing.
• Frequently stand, walk, sit and utilize eye/hand coordination and color definition.
• Occasionally reach above shoulder, regularly required to lift and/or carry up to 40 lbs.
• Occasionally walk on uneven surfaces.