Claims Lifecycle Optimization Specialist

Med--metrix; United States; Remote; USD 85,000 - 120,000; Full time

Job summary

Med-Metrix seeks a Billing Optimization Analyst to drive accurate and timely claim submissions across Medicare, Medicaid, and commercial payers. You will diagnose root causes, coordinate with billing, IT, and operations, and implement lasting fixes to prevent recurrence.

You will analyze claim barriers, lead improvement initiatives, and develop guidance to reduce denials and delays while ensuring PHI is protected under HIPAA standards.

Qualifications

• Bachelor's degree in healthcare administration, business, finance, or a related field
• 4+ years of progressive hospital billing experience with resolution of complex claims
• End-to-end knowledge of institutional claim lifecycle, including edits, split-billing, bill holds, rejections and corrected claims
• In-depth knowledge of Medicare, Medicaid, managed care, and commercial payer rules and submission requirements
• Proficiency with UB-04 and 837I, revenue codes, bill types, modifiers, and payer-specific edits
• Ability to identify root causes, lead cross-functional teams, and sustain results independently
• Experience researching claim-generation issues in Epic Resolute or similar systems
• Experience with clearinghouse tools, payer portals, claim scrubbing, and reporting tools
• Exposure to multiple hospitals or payer environments
• Strong MS Office skills
• Excellent written and verbal communication skills

Responsibilities

• Serve as SME for hospital claim lifecycle from final coding to claim creation and transmission
• Research and resolve complex billing edits, split-billing, bill holds, rejections, and late charges
• Apply Medicare, Medicaid, and payer rules to determine correct billing for complex scenarios
• Analyze recurring barriers and identify root causes across processes and systems
• Lead sessions with billing leaders to review scenarios, findings, and resolutions
• Collaborate with operational, clinical, reimbursement, coding, IT, and vendor teams to improve edits and workflows
• Monitor metrics like first-pass rate, DNFB, rejection trends, and throughput to sustain improvements
• Develop billing guidance and standard work to prevent recurrence
• Advise leadership on billing risks, priorities, and financial impact
• Other duties as assigned
• Ensure PHI handling per HIPAA standards
• Comply with information security and HIPAA policies

Skills

Billing knowledge

Root-cause analysis

Cross-functional collaboration

Communication

Independent judgment

HIPAA/PHI handling

Education

Bachelor's degree in healthcare administration/related field

Tools

Epic Resolute

Clearinghouse tools

Job description

Med-Metrix seeks a Billing Optimization Analyst to drive accurate and timely claim submissions across Medicare, Medicaid, and commercial payers. You will diagnose root causes, coordinate with billing, IT, and operations, and implement lasting fixes to prevent recurrence.

You will analyze claim barriers, lead improvement initiatives, and develop guidance to reduce denials and delays while ensuring PHI is protected under HIPAA standards.