Medical Biller: resume screening criteria template

Medical billing is a results game. The best billers know their numbers and can prove they kept revenue flowing. Look for candidates who cite clean claim rates (percentage of claims paid on first submission), days in accounts receivable (how long it takes to collect payment), collection rates (percentage of billed charges actually collected), or denial rates. A strong candidate might say they maintained a 97% clean claim rate or reduced A/R days from 55 to 38. These metrics show they understand the business impact of their work and take ownership of outcomes, not just tasks.

Strong evidence: Clean claim rate 95%+, A/R days under 45, collection rate above 95%, reduced denials by X%, successfully appealed $X in denied claims, posted $X in payments monthly

Red flag: No mention of metrics, outcomes, or results. Vague phrases like 'processed claims' or 'handled billing' without any indication of volume, accuracy, or financial impact. This suggests they showed up but never measured whether they were actually good at the job.

Medical billing lives in specialized software, and experience with your platform (or similar ones) means faster onboarding and fewer errors. Look for candidates who name specific systems: Kareo, AdvancedMD, athenahealth, eClinicalWorks, DrChrono, NextGen, or Tebra. Even better if they have used multiple systems, which shows adaptability. A candidate who says 'proficient in EMR/billing software' without naming tools is hiding lack of depth. Also look for mentions of clearinghouses (Availity, Change Healthcare, Trizetto) and payer portals, which indicate they know the full claim submission ecosystem.

Strong evidence: Names 2+ specific billing platforms, mentions clearinghouse experience, references payer portals (Availity, Navinet), describes customizing claim scrubbers or reports, shows comfort learning new systems

Red flag: Only lists 'Microsoft Office' or 'EMR experience' without naming actual billing software. Uses vague terms like 'various billing systems.' If they have been billing for years but cannot name the software, they were likely doing minimal data entry, not true billing work.

Submitting claims is half the job. The real skill is getting denied claims paid. Strong billers treat denials as puzzles to solve, not dead ends. Look for evidence they tracked denials, identified patterns (like a payer that always rejects a certain code), filed appeals, and won. Phrases like 'reduced denials,' 'overturned X% of denials,' 'appealed and recovered $X,' or 'maintained denial rate under 5%' show persistence and problem-solving. Also look for mention of working denials within a specific timeframe (like 7 days), which shows urgency. A biller who never mentions denials likely ignored them and left money on the table.

Strong evidence: Reduced denial rate by X%, successfully appealed X% of denials, recovered $X in denied claims, worked denials within 7 days, identified payer-specific denial patterns, references specific denial codes (CO-16, CO-97, etc.)

Red flag: Resume mentions only claim submission with no reference to denials, appeals, or follow-up. No evidence of payer communication or problem-solving. This candidate probably submitted claims and moved on, never fighting for the practice's revenue.

Medical billers do not need to be certified coders, but they must catch coding errors before claims go out. Look for candidates who reference CPT codes, ICD-10 codes, modifiers, and coding edits. Phrases like 'reviewed coding for accuracy,' 'corrected coding errors,' 'ensured proper modifier usage,' or 'worked with providers to clarify documentation' show they understand the clinical side. Specialty-specific coding experience is a plus (E/M levels for primary care, surgical codes for specialties, behavioral health codes for mental health). A candidate who never mentions codes or only says 'entered charges' likely did not understand what they were billing.

Strong evidence: References CPT, ICD-10, HCPCS codes, mentions modifiers (-25, -59, -GT, etc.), describes catching coding errors, worked with providers on documentation, mentions coding edits or NCCI, specialty-specific code knowledge

Red flag: No mention of codes, modifiers, or coding accuracy. Resume focuses only on 'data entry' or 'processing claims' without any indication they understood the clinical content. This person was a typist, not a biller.

Every payer has different rules, and experienced billers know the quirks. Look for candidates who mention specific payers (Medicare, Medicaid, Blue Cross, Aetna, UnitedHealthcare) and show they understand payer-specific requirements. Phrases like 'verified benefits,' 'checked eligibility,' 'prior authorization,' 'timely filing limits,' 'coordination of benefits,' or 'secondary billing' indicate depth. Medicare experience is especially valuable because it is complex and often the foundation for other payers. A candidate who says 'billed all insurance companies' without specifics likely does not know the nuances that prevent denials.

Strong evidence: Names specific payers, mentions Medicare/Medicaid rules, references prior authorization, discusses timely filing deadlines, describes coordination of benefits, mentions credentialing or payer enrollment

Red flag: Generic phrases like 'worked with insurance companies' without naming any. No mention of eligibility verification, prior auth, or payer-specific processes. This suggests surface-level experience that will lead to avoidable denials.

Billing errors cost money and time. The best billers are meticulous and curious. Look for evidence they caught mistakes, identified patterns, or improved processes. Phrases like 'audited claims before submission,' 'identified recurring errors,' 'created checklists to reduce mistakes,' 'reconciled EOBs to find underpayments,' or 'trained staff on common errors' show they think beyond their immediate task. Also look for problem-solving examples: a candidate who figured out why a certain payer kept denying claims, or who streamlined a workflow to reduce claim rejections. Attention to detail is hard to fake, it shows up in outcomes.

Strong evidence: Describes catching errors before submission, mentions auditing or quality checks, identified patterns in denials or underpayments, improved processes to reduce errors, reconciled discrepancies, trained others

Red flag: Resume is full of typos, inconsistent formatting, or vague language. No evidence of quality control, auditing, or process improvement. If they cannot proofread their own resume, they will not catch billing errors either.