Billing Optimization Analyst - Hospital

Job Purpose

The Billing Optimization Analyst is an experienced hospital billing professional responsible for evaluating and resolving barriers that prevent accurate and timely claim submission. The analyst applies working knowledge of Medicare, Medicaid, managed care, and commercial payer requirements across the claim-generation lifecycle, including edits, claim splits, bill holds, rejections, late charges, and other exceptions. Working collaboratively with billing, operational, clinical, reimbursement, and technology teams, the analyst shares findings and practical recommendations that improve first-pass clean-claim performance, reduce DNFB, and accelerate revenue capture. Duties & Responsibilities

• Support the hospital claim-generation lifecycle, from final coding and charge capture through claim creation, validation, and transmission
• Research and resolve billing edits, claim splits, bill holds, rejections, late charges, stop bills, and other exceptions that delay claims from being released
• Apply Medicare, Medicaid, managed care, and commercial payer billing requirements to support accurate and timely claim submission
• Analyze recurring claim barriers and help identify root causes across processes, system configuration, payer rules, and upstream workflows
• Collaborate with billing leaders and team members to review billing scenarios, share findings, and recommend practical resolution steps
• Partner with operational, clinical, reimbursement, coding, IT, and vendor teams to support improvements to edits, work queues, workflows, and escalation processes
• Monitor first-pass clean-claim rate, bill-hold days, DNFB, rejection trends, and billing throughput to identify improvement opportunities
• Document billing scenarios, root causes, recommended actions, and reusable guidance to support team consistency

Qualifications

• 2–3 years of hospital billing experience, including hands-on experience resolving claims before submission
• Working knowledge of the end-to-end institutional claim lifecycle, including claim edits, split-billing scenarios, bill holds, rejections, late charges, stop bills, and corrected or replacement claims
• Knowledge of Medicare, Medicaid, managed care, and commercial payer billing rules, claim formats, and submission requirements
• Familiarity with UB-04 and 837I requirements, revenue codes, bill types, condition and occurrence codes, modifiers, claim frequency codes, and payer-specific edits
• Ability to research why a claim cannot be released, identify the appropriate resolution or escalation path, and clearly explain the next action to team members and stakeholders
• Proficiency in Excel and comfort reviewing billing, edit, hold, and rejection data for trends
• Clear written and verbal communication skills with a collaborative, consultative approach to problem-solving
• Experience researching claim-generation issues in Epic Resolute or a comparable patient accounting system
• Experience using clearinghouse tools, payer portals, claim scrubbers, and reporting tools
• Exposure to multiple hospitals, facilities, or payer environments
• Experience sharing billing guidance or helping team members work through claim issues
• Applies hands-on billing knowledge to identify, investigate, and resolve claim edits, splits, holds, rejections, and submission barriers
• Demonstrates working knowledge of Medicare, Medicaid, managed care, and commercial payer requirements and proactively seeks guidance when needed
• Uses analytical thinking to evaluate billing data and claim-level details, identify patterns and root causes, and recommend practical next steps
• Builds effective partnerships by listening, asking targeted questions, communicating findings clearly, and collaborating with stakeholders on solutions
• Collaborates effectively with clinical, operational, financial, reimbursement, coding, and technology teams to support revenue cycle improvement initiatives
• Takes ownership of assigned issues by driving resolution or appropriate escalation while maintaining accurate and complete documentation

Working Conditions

• Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes
• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
• Work Environment: The noise level in the work environment is usually minimal

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

Originally posted on Himalayas