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About the Role

The Professional Billing Specialist is responsible for managing all professional billing requirements and accounts receivable tasks, ensuring compliance with regulatory and payor guidelines.

Responsibilities

• Coordinate payor denial and appeal follow-up activities for timely response and processing.
• Review denial accounts for categorization, appeal level, and specific appeal requirements.
• Communicate global payer issues with the payer relations team.
• Communicate and coordinate with various individuals, assisting with monitoring daily appeal follow-up and denial activities.
• Maintain the healthcare tracking tool/application, including user access, software updates, and end-user training.
• Monitor Claim Edit and Denial Management work queues to ensure full resolution.
• Ensure medical records requests are completed and submitted within 48 hours.
• Track denials on a database to determine outcomes, collecting and analyzing data, reporting metrics and trends.
• Organize data and activity for retrievable and timely follow-up on appeals.
• Assist with the coordination of denial and review activities and materials for committee meetings.
• Support projects and initiatives of the Billing and Denials Management teams, including coordinating meetings and preparing documents.
• Build and maintain relationships with payer representatives.

Requirements

• Epic PB Resolute experience.
• 5 years of experience in a Healthcare/Hospital Revenue Cycle Environment, including Third Party Collection/AR Receivables.
• Experience with Healthcare Revenue Cycle revenue management EDI Transaction sets, including 837P.
• Knowledge of insurance contract rates and terms.
• Understanding of Registration and Collections.
• Understanding of Government and Managed Care billing, coverage, and payment rules.
• Ability to comprehend payor 835 and paper EOB responses.
• Understanding of CCI edits, CPT, HCPCS, ICD-10, and Revenue Codes.
• Intermediate Excel skills.
• Excellent computer skills, especially spreadsheet and database applications.
• Knowledge of managed care patient financial systems and specific billing and payment standards for hospital services.
• Thorough understanding of managed care payment methodologies and principles.
• Certification in Epic PB Resolute or agreement to obtain certification within 12 months of hire.
• Bachelor’s Degree or equivalent combination of education and experience.

Skills

• Epic PB Resolute
• Healthcare/Hospital Revenue Cycle
• Third Party Collection/AR Receivables
• EDI Transaction sets (837P)
• Insurance contract rates and terms
• Registration and Collections
• Government and Managed Care billing, coverage, and payment rules
• Payor 835 and paper EOB responses
• CCI edits, CPT, HCPCS, ICD-10, Revenue Codes
• Excel (Intermediate)
• Spreadsheet applications
• Database applications
• Managed care patient financial systems
• Managed care payment methodologies
• SQL
• Crystal Reports

Location

• Remote

Work Type

• Full-time

Experience Level

• 5 years

Education Level

• Bachelor's Degree

Salary/Compensations

• $24.16 - $36.24

About the Company

• Shriners Children’s is an organization that respects, supports, and values each other.
• Named as the 2025 best mid-sized employer by Forbes.
• Engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact.
• Fosters a learning environment that values evidenced based practice, experience, innovation, and critical thinking.
• Compassion, integrity, accountability, and resilience define them as leaders in pediatric specialty care.
• With 20+ hospitals, outpatient clinics, ambulatory care centers and outreach locations across the globe, they provide excellent care to children up to age 18 regardless of their family’s ability to pay or insurance status.