Insurance Billing Professional (hybrid), full time, days

Holland Hospital•Holland, MI

2d•Hybrid

About The Position

The Insurance Billing Professional is responsible for accurate, compliant, and timely claim submission and follow-up to government and commercial payers to secure appropriate reimbursement for services provided. This role functions as an advanced individual contributor with a primary emphasis on denial prevention and first-pass yield: proactively identifying documentation, coding, eligibility, authorization, and claim-edit risks; applying payer policy knowledge; and driving corrective action to reduce avoidable denials and rework. The position independently manages complex accounts, partners with internal stakeholders to address root causes, maintains strict patient confidentiality, and supports revenue cycle initiatives that improve cash flow, reduce accounts receivable, and enhance the patient financial experience.

Requirements

High school diploma/GED, or higher education
One (1) of the following credentials or equivalent: CPC, CPB, CBCS, COC, CIC, CRCR, HBI, HFMA certificates preferred
Maintains credential continuing education (CE) requirements as applicable.
Strong written and verbal communication skills with the ability to translate denial language into clear, actionable next steps for internal partners.
Proficient computer skills, including EHR/billing systems, claim editing tools, and payer portals; strong attention to detail and data accuracy.
Strong analytical skills to identify denial trends, determine root causes, quantify impact, and recommend corrective actions.
Strong organizational skills with the ability to independently prioritize aged/at-risk accounts, meet deadlines, and manage high-volume work.
Critical thinking and sound judgment; timely escalation of high-risk denial trends, payer behavior changes, and reimbursement threats.

Nice To Haves

Intermediate to advanced Excel/reporting skills (filters, pivots, lookups) and comfort translating data into operational action.
Experience building/maintaining denial reference tools (payer grids, tip sheets, denial playbooks) and supporting standard work.
Ability to develop training materials and provide coaching/training to other team members on denial prevention and clean-claim best practices.

Responsibilities

Proactively identifies denial risk prior to billing by validating key claim elements (authorization, eligibility, medical necessity indicators, modifiers, diagnosis/procedure alignment, and required documentation) and coordinating corrections to support clean claim submission.
Performs rigorous claim edit review and resolves preventable edits to maximize first-pass acceptance and minimize rejections and rework.
Monitors denial and rejection patterns by payer, plan, and denial category; distinguishes one-off issues from systemic drivers and prioritizes interventions based on financial and operational impact.
Partners with Denials Analysts and Leadership to conduct root cause analysis and implement prevention actions (standard work, education, workflow changes) to reduce repeat denials and Hospital A/R.
Maintains and updates denial prevention tools (payer requirement grids, reference files, tip sheets) to ensure current guidance is available to staff and consistently applied.
Communicates payer policy changes, recurring denial themes, and emerging risks with clarity and urgency; escalates trends appropriately to protect reimbursement.
Ensures timely and accurate billing to primary, secondary, and tertiary payers and initiates patient balance billing in accordance with policy and regulatory requirements.
Monitor assigned insurance work queues to verify encounters move through the system efficiently; proactively address barriers and escalates systemic issues as needed.
Reviews and resolves encounters in assigned queues including, but not limited to, Charge Error DOS, Adjustments, and Client Bill workqueues.
Independently investigates and resolves payer rejections, denials, and underpayments
Assists with resolution of encounters from other staff members’ work queues to prevent backlogs and maintain service levels.
Maintains thorough, timely account notes and follow-up actions that are clear, complete, and audit-ready.
Runs, distributes, and reviews ATB and denial-related reports (or similar) for assigned areas; identifies trends, risks, and priority follow-up actions.
Translates reporting into actionable recommendations (training needs, workflow changes, escalation items) and communicates results to leadership and partners.
Updates and maintains accurate payer reference information (contacts, addresses, phone numbers, requirements) to support efficient payer communication.
Demonstrates consistent compliance with HIPAA, payer policies, and applicable regulations; maintains patient confidentiality in all interactions.
Actively participates in continuous quality improvement initiatives to enhance denial prevention, accuracy, timeliness, and outcomes.
Demonstrates initiative and resourcefulness by escalating high-risk issues and sharing payer changes, recurring problems, and recommended solutions with management.
Assisting leadership with daily, weekly and monthly audit review of team members and various workqueues.
Supports onboarding and training for new hires and provides ongoing coaching to team members as assigned, with emphasis on clean-claim practices and denial prevention.
Partners with the Denials Team and Leadership to provide ongoing education and reinforce standard work.
Helps foster a collaborative culture by participating in team goal setting, sharing input, and contributing to a high-performing team.
Completes projects requested by Leadership in a timely, accurate, and professional manner.
Continues to demonstrate proficiency in Insurance Billing and Follow-up representative/associate responsibilities and essential functions.