Description

Job Summary
Mainstreet Pediatrics is an independent pediatric primary care practice in Parker, Colorado, seeking an experienced Medical Billing & Revenue Cycle Specialist to join our team in-house.

We are looking for someone who understands that successful revenue cycle management is much more than simply submitting claims. This position will take ownership of the revenue cycle from encounter → clean claim → adjudication → denial/underpayment → correction/appeal → payment.

The ideal candidate is highly organized, detail-oriented, persistent, and comfortable working directly with insurance companies, payer representatives, provider portals, and our practice management/EHR system to ensure claims are submitted correctly, payments are received timely, denials are resolved, and outstanding accounts receivable is actively worked.

Experience with pediatric medical billing, eClinicalWorks, Colorado Medicaid/Health First Colorado, Colorado Access, commercial insurance, and TRICARE is highly desirable.

This is a full-time position, on-site initially, with the potential to transisition to a hybrid work arrangement based on demonstrated performance, proficiency, and operational needs.  

Requirements

Responsibilities
The Medical Billing & Revenue Cycle Specialist will be responsible for managing and monitoring the practice's revenue cycle, including:

Review encounters and claims for accuracy and completeness prior to submission.
Submit clean claims electronically and ensure claims are accepted by clearinghouses and payers.
Identify and promptly resolve claim rejections.
Monitor claims through the adjudication process rather than simply waiting for payment.
Review EOBs and ERAs for appropriate payment, adjustments, denials, and patient responsibility.
Identify insurance underpayments and pursue additional reimbursement when appropriate.
Research and resolve denied claims.
Prepare and submit corrected claims, reconsiderations, and formal payer appeals.
Follow up aggressively and consistently on outstanding insurance accounts receivable.
Monitor aging reports and prioritize claims requiring immediate action.
Identify claims approaching payer timely-filing or appeal deadlines.
Work directly with insurance companies, payer representatives, and provider relations departments to resolve outstanding claims.
Maintain detailed documentation of payer communications and claim follow-up.
Post and reconcile insurance payments, adjustments, and patient responsibility when necessary.
Identify payer-specific billing requirements and recurring denial trends.
Recognize potential credentialing, enrollment, or payer configuration problems affecting reimbursement and escalate them promptly.
Assist with insurance eligibility, coordination-of-benefits, and payer-related patient account issues.
Research discrepancies between expected reimbursement and actual payment.
Help resolve patient billing questions when the underlying issue involves insurance processing or claim adjudication.
Provide management with clear reporting regarding A/R, denials, outstanding claims, payer issues, and revenue-cycle trends.
Identify systemic billing problems rather than addressing claims individually when a broader issue exists.
Recommend and implement workflow improvements designed to reduce denials, accelerate payment, and improve overall revenue-cycle performance.

Qualifications Required

Previous professional medical billing and/or revenue cycle management experience.
Strong understanding of the complete medical claims lifecycle.
Experience working insurance A/R and resolving unpaid or incorrectly paid claims.
Experience researching and resolving claim denials and rejections.
Experience preparing corrected claims and payer appeals.
Working knowledge of CPT, ICD-10, HCPCS codes, modifiers, and general medical billing rules.
Ability to interpret EOBs and ERAs.
Ability to identify potential underpayments and reimbursement discrepancies.
Experience using insurance payer portals and communicating directly with payer representatives.
Excellent organizational skills and attention to detail.
Strong written and verbal communication skills.
Ability to independently research problems and follow them through to resolution.
Ability to manage multiple outstanding issues and prioritize claims based on age, value, and filing deadlines.

Preferred

Pediatric medical billing experience.
Experience with eClinicalWorks (eCW).
Experience billing Health First Colorado/Colorado Medicaid and Colorado Access.
Experience working with major commercial payers, including UnitedHealthcare and Aetna.
Experience with TRICARE.
Experience identifying and resolving payer enrollment or credentialing-related claim issues.
Experience with payer appeals and complex denial resolution.
AAPC or other recognized billing/coding certification is a plus but is not required.
What We're Looking For
We are specifically looking for someone who takes ownership of the revenue cycle.

If a claim is rejected, we expect you to determine why.

If a claim is denied, we expect you to research the denial and determine the appropriate next step.

If a payer underpays a claim, we expect you to recognize it and pursue the correct reimbursement.

If a payer says a claim is processing, we expect appropriate follow-up until the claim is actually resolved.

If multiple claims are experiencing the same problem, we expect you to recognize the pattern and investigate the underlying cause.

The goal is not simply to "work claims." The goal is to make sure Mainstreet Pediatrics is appropriately reimbursed for the care our providers deliver.

Why Mainstreet Pediatrics?

Mainstreet Pediatrics is an independent pediatric practice that has served families in Parker and the surrounding community for years. Because our billing and revenue cycle directly affect our ability to care for our patients and support our employees, this position is an important part of our practice.

Unlike a large billing company where an account may be one of dozens or hundreds assigned to a team, you will work directly with our leadership, providers, and administrative staff and will be able to see the results of your work.

We value accountability, communication, problem-solving, and people who take pride in seeing an issue all the way through to resolution.