Billing Readiness Specialist

Job Description

Job Description

Overview

The Billing Readiness Specialist serves as a critical bridge between front office operations, authorization workflows, and the billing department by ensuring patient accounts are accurately configured and financially ready to support timely clean claim submission and continuity of care.

This role is responsible for validating insurance setup, payer plan selection, benefit verification, patient financial responsibility, and authorization readiness to ensure claims are routed correctly and reimbursement delays are minimized. The Billing Readiness Specialist proactively identifies account discrepancies that could result in claim denials, incorrect patient balances, delayed reimbursement, or billing errors.

In addition to traditional benefit verification responsibilities, this position plays a key role in revenue protection by validating discipline-specific payer requirements, payer crossover configurations, and claim routing logic prior to billing activity.

The Billing Readiness Specialist supports clean claim submission, improves point-of-service collection accuracy, and reduces downstream rework by ensuring accounts are properly configured before treatment and billing occur.

Responsibilities

The Billing Readiness Specialist is responsible for ensuring patient accounts are accurately configured and financially cleared prior to claim submission and ongoing treatment. This role serves as a critical operational support function between intake, authorization workflows, and billing by validating insurance setup, benefit coverage, payer configuration, patient responsibility, and billing readiness requirements.

The Billing Readiness Specialist plays a key role in preventing avoidable denials, improving claim accuracy, reducing patient balance discrepancies, and supporting efficient reimbursement workflows through proactive account review and issue resolution.

• Insurance & Eligibility Verification
• Verify active insurance coverage and eligibility
• Validate accurate payer and plan selection within the practice management system
• Confirm subscriber/member demographic accuracy
• Review coordination of benefits and secondary insurance information
• Ensure payer setup aligns with discipline-specific billing requirements

Benefit Verification

• Verify patient financial responsibility including:
• Copays
• Coinsurance
• Deductibles
• Visit limitations
• Referral requirements
• Coverage limitations
• Accurately document benefit information within the patient account

Payer Configuration & Billing Readiness Review

• Review patient accounts to ensure proper billing setup prior to claim submission
• Validate payer hierarchy and discipline-specific payer routing requirements
• Identify payer crossover issues that may impact claim routing or patient balances
• Ensure accounts are configured correctly to prevent billing bypass logic and inaccurate patient responsibility transfers
• Correct or escalate account setup discrepancies prior to billing activity

Authorization Readiness Oversight

• Confirm whether authorization is required for services rendered
• Review authorization status, visit counts, effective dates, and applicable CPT code alignment
• Identify missing, incomplete, or expired authorizations
• Escalate authorization concerns to the appropriate operational teams

Revenue Integrity & Denial Prevention

• Perform pre-billing account audits to identify issues impacting reimbursement
• Prevent avoidable denials related to registration, payer setup, eligibility, or authorization discrepancies
• Support clean claim submission processes by ensuring account accuracy prior to billing
• Assist in reducing manual rework and payment delays caused by setup errors

Communication & Collaboration

• Communicate account discrepancies and payer concerns to clinics, front office staff, authorization teams, and billing personnel
• Escalate recurring trends or operational issues impacting reimbursement
• Collaborate with operational leadership to improve workflow accuracy and payer setup consistency
• Assist with identifying training opportunities related to registration and insurance setup deficiencies

Qualifications

• High School Diploma or GED required
• Associate degree in a related field preferred
• 3+ years of experience in medical billing, insurance verification, authorizations, or healthcare revenue cycle required
• Experience with Medicare, commercial insurance, and managed care preferred
• Outpatient therapy experience preferred
• Experience in medical billing, insurance verification, healthcare revenue cycle, or related healthcare operations preferred
• Knowledge of insurance eligibility, benefit verification, and payer requirements
• Understanding of authorization workflows and reimbursement processes
• Familiarity with outpatient therapy billing workflows preferred
• Strong attention to detail and organizational skills
• Ability to analyze payer setup and account configuration discrepancies
• Strong communication and problem-solving skills
• Experience with EMR and/or practice management systems preferred

Preferred Skills

• Understanding of discipline-specific payer carve-outs and billing requirements
• Knowledge of Medicare, commercial insurance, managed care, and therapy-specific billing workflows
• Ability to identify operational trends contributing to denials or delayed reimbursement
• Experience working in high-volume healthcare billing environments

Key Performance Indicators (KPIs)

• Reduction in eligibility-related denials
• Reduction in authorization-related denials
• Reduction in payer setup and registration errors
• Improvement in clean claim submission rates
• Accuracy of patient responsibility configuration
• Timeliness of billing readiness review completion
• Reduction in manual billing corrections and rework
• Escalation resolution turnaround time