Senior Medical Claims & Accounts Receivable Analyst

Pioneers Medical Center•Meeker, CO

5d•Hybrid

About The Position

The Senior Medical Claims and Accounts Receivable Analyst will manage and actively monitor assigned AR to ensure timely and accurate reimbursement. This role involves analyzing aging reports, prioritizing accounts, and developing strategies to reduce outstanding AR. The analyst will identify trends in unpaid, underpaid, and delayed claims, maintain accurate documentation, and escalate complex issues. A key part of the role is conducting detailed reviews of rejected, denied, and underpaid medical claims to determine root causes, researching payer policies, and preparing/submitting corrected claims, reconsiderations, and appeals. The analyst will also investigate payment discrepancies, compare payments against expected reimbursement, and identify systematic issues affecting revenue. Collaboration with various teams, including billing, coding, clinical, and administrative, is essential for resolving reimbursement problems. The position requires applying knowledge of ICD-10-CM, CPT, HCPCS, modifiers, NCCI edits, and payer-specific requirements to review claims and identify errors. The analyst will also monitor key AR and claims metrics, analyze trends, prepare reports, and recommend process improvements to enhance collections, reduce denials, and improve cash flow. This role may also involve assisting in developing and maintaining denial-management and AR workflows and identifying opportunities for automation and staff education.

Requirements

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.
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.

Nice To Haves

Professional certification in medical coding and/or billing is strongly preferred.
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.

Responsibilities

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.
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.
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.
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.
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.