Medical Biller

Job Summary

Medical Biller

The Medical Biller reports to the Billing Manager in person at out office in Ontario, CA and is responsible for the accurate, compliant, and timely billing of clinical laboratory services, including blood testing, microbiology/culture testing, and toxicology services. This role requires strong expertise in Medicare Part A vs Part B billing, skilled nursing facility (SNF) workflows, and commercial payer laboratory billing rules. The Medical Biller manages claims from Pending Review through payment resolution while ensuring full compliance with Medicare, Medicaid, and commercial payor regulations.

No Remote Work Available

Supervisory Responsibilities

• None

Essential Duties and Responsibilities

Laboratory Billing & Claims Management

• Review laboratory patient demographics, insurance, ordering provider, and facility information.
• Prepare, review, and submit insurance claims for laboratory services provided by Brio Clinical Partners, including blood testing, microbiology/culture, and toxicology.
• Accurately apply CPT, HCPCS, and ICD-10 codes in accordance with payer and regulatory guidelines.
• Distinguish and bill correctly under Medicare Part A vs Medicare Part B, Medicare Advantage, Medicaid, and commercial insurance plans.

Coding, Medical Necessity & Compliance

• Review claims for medical necessity in compliance with Medicare LCDs/NCDs and commercial payer policies.
• Ensure proper toxicology billing, including correct differentiation between screening vs confirmatory testing, frequency limits, and unit reporting.

• Identify and resolve coding, diagnosis, or documentation issues prior to claim submission.
• Maintain strict adherence to Brio Clinical Partners’ compliance policies and HIPAA regulations.

Insurance Verification & Authorization

• Verify insurance eligibility and benefits prior to billing when required.
• Identify payer authorization or referral requirements for laboratory services.
• Confirm Brio’s in-network or out-of-network status and apply correct billing methodology.

Payment Posting & Reconciliation

• Accurately post payments, contractual adjustments, denials, and refunds from EOBs and ERAs.
• Reconcile payments against Brio’s expected reimbursement schedules and contracted rates.
• Identify underpayments, overpayments, and payer processing errors and escalate to management as appropriate.

Denials Management & Appeals

• Research and resolve claim denials related to:
• Medicare Part A vs Part B determinations
• Medical necessity
• Coverage or authorization issues
• Coding or billing errors
• Prepare and submit appeals with supporting clinical and billing documentation.
• Track appeal outcomes and identify trends to reduce future denials.

SNF & Client Billing Support

• Collaborate with skilled nursing facilities and internal teams regarding census reports, patient status, and billing responsibility.
• Generate and manage client invoices for facility-responsibility or non-covered services.
• Communicate billing outcomes clearly and professionally with SNF partners and internal stakeholders.

Reporting & Productivity

• Maintain accurate billing logs, work queues, and documentation.
• Meet Brio Clinical Partners’ productivity, accuracy, and turnaround time standards.
• Prepare billing, payment, and denial reports for leadership review.

Quality Assurance & Process Improvement

• Identify recurring billing issues and recommend workflow improvements.
• Stay current on changes to laboratory billing regulations, Medicare policies, and payer requirements relevant to Brio’s testing services.

Billing Claims

• Submit clean and accurate insurance claims (electronic and paper) in compliance with payer and regulatory guidelines
• Review claims for completeness, coding accuracy, and required documentation prior to submission
• Ensure timely filing limits are met for all payers
• Maintain accurate claim notes and follow-up logs

EOB Review / Negotiations / Claim Tracing

• Analyze Explanation of Benefits (EOBs) for accuracy of payments, adjustments, and denials
• Identify underpayments, incorrect contractual adjustments, and non-covered charges

• Identify claims eligible for negotiation and report them to the supervisor for review
• Escalate unresolved issues when necessary
• Perform systematic claim follow-up with insurance payers via portals, phone calls, and written correspondence
• Investigate delayed, pending, or lost claims and take corrective action
• Obtain claim status updates, reference numbers, and resolution timelines
• Identify payer trends impacting reimbursement or processing delays
• Ensure claim aging is minimized, and claims are resolved within expected turnaround times

General

• Performs other duties as assigned.
• May assist with training, coaching, and the development of coworkers and students.
• Must take all assigned Human Resources trainings and classes
• Responsible for attending all department and staff meetings

Required Qualifications

• Minimum of 4–5 years of medical billing experience, with direct experience in clinical laboratory billing.
• Medical billing certificate or degree, required.
• Demonstrated experience billing blood testing, microbiology/culture testing, and toxicology services.
• Strong working knowledge of:
• CPT, HCPCS, and ICD-10 coding

• Medicare Part A vs Part B laboratory billing
• SNF laboratory billing workflows
• Toxicology billing rules and frequency limitations
• Proficiency with billing systems, clearing houses, and payer portals.
• High level of attention to detail and ability to manage multiple deadlines.

Preferred Qualifications

• Experience billing for skilled nursing facilities (SNFs), hospitals, or reference laboratories.
• Familiarity with Medicare LCD/NCD policies related to laboratory and toxicology testing.
• Prior experience with audits, appeals, or compliance reviews.
• Knowledge of California and multi-state laboratory billing requirements (as applicable).

Skills & Competencies

• Strong analytical and problem-solving skills
• Clear written and verbal communication
• Ability to work independently and collaboratively
• Time management and organizational skills
• Commitment to accuracy, compliance, and confidentiality

Physical Requirements

• Prolonged periods of sitting and a desk and working on a computer.

• Prolonged periods of standing and working at a copier.
• Must be able to lift to 25 pounds and sit/stand for long periods of time.