Billing Specialist

The Medical Billing Specialist supports a high-volume pediatric urgent care practice with a strong Medicaid and managed Medicaid payer mix. This role is responsible for accurate coding, claim submission, and follow-up for episodic urgent care visits, procedures, and ancillary services, ensuring timely reimbursement while maintaining compliance with Medicaid and payer-specific requirements.

Key Responsibilities

• Review urgent care provider documentation and assign accurate CPT, ICD-10, and HCPCS codes
• Bill high-volume pediatric urgent care services, including E/M levels, minor procedures, splinting, laceration repair, and diagnostic services
• Submit and manage claims primarily for Medicaid and Medicaid MCOs, with some commercial payers
• Apply correct modifiers for urgent care services, procedures, and multiple services rendered in a single visit
• Verify Medicaid eligibility, managed care enrollment, and urgent care coverage rules
• Identify, research, and resolve denials related to medical necessity, bundling, modifiers, frequency limits, and timely filing
• Prepare and submit corrected claims and appeals in accordance with state Medicaid guidelines
• Post payments, contractual adjustments, and reconcile ERAs/EOBs
• Monitor accounts receivable, track claim aging, and prioritize timely follow-up
• Work closely with clinical and front-office teams to resolve documentation, registration, or coding issues

Qualifications

• High school diploma or equivalent (Associate degree preferred)
• Minimum 2 years of medical billing experience in urgent care, emergency, or pediatric physician practice settings
• Strong experience with Medicaid and managed Medicaid billing
• Solid understanding of urgent care E/M coding, procedure coding, and modifier usage
• Experience with EHR/EMR and practice management systems
• Ability to work accurately in a fast-paced, high-volume environment

Preferred Certifications

• Certified Professional Biller (CPB)
• Certified Medical Reimbursement Specialist (CMRS)
• Urgent care or pediatric billing experience strongly preferred

Skills & Competencies

• Knowledge of Medicaid urgent care policies and payer-specific edits
• Strong denial management and appeal skills
• High attention to detail with excellent time-management
• Clear communication with payers, providers, and operational staff
• Commitment to compliance, accuracy, and patient confidentiality