A practice manager in a four-physician group told us last month that her billing position had been open since June. She had interviewed eleven people. Three had real billing experience and all three took hospital jobs paying more than the practice could match. The other eight had none. Meanwhile the one remaining biller was working denials at night and the over-90 AR had doubled.
Her story is the common one this year. Experienced billers are scarce, hospital systems and billing companies can pay more, and remote work has widened the pool of employers competing for the same people. Independent practices that wait for an experienced candidate at the old wage are waiting a long time. The practices that are filling the seat are doing something different: hiring for aptitude and training for the job.
Key takeaways
- Hire for attention to detail, numeric comfort and persistence, tested with a 30-minute practical exercise, rather than for years of billing experience you cannot find.
- Train in a fixed sequence, foundation to posting to rejections to denials, with observable checkpoints at 30, 60 and 90 days.
- Expect a third of full productivity at 30 days and close to full on routine work at 90. Budget the ramp and the trainer's time.
- Retention is wage reviews against current local postings, remote days once independent, ownership of something specific, and never making one person the only one who knows how anything works.
What to hire for when you cannot hire experience
Billing is a job of rules, exceptions and follow-through. The people who do it well are careful, comfortable with numbers, unbothered by repetitive work, and persistent on the phone. None of that requires prior billing experience, and a resume does not show it. A short practical test does.
| Trait | How to test it in an interview |
|---|---|
| Attention to detail | A one-page mock registration form with five planted errors (transposed DOB, wrong subscriber relationship, missing group number). Ask the candidate to find them. |
| Numeric comfort | A mock remittance with allowed, paid, adjustment and patient responsibility amounts. Ask what the patient owes and why. |
| Reading dense material | A paragraph from a payer policy. Ask the candidate to explain it in plain words. |
| Persistence and tone | A role-play: the payer says the claim was never received. What do you say next? |
| Reliability | References, asked specifically about attendance and follow-through, not about personality. |
Candidates who have done front desk, pharmacy technician, bank teller, insurance customer service or bookkeeping work often test well. So do people returning to work after time away. We would rather have a careful person with no billing background than an experienced biller who cannot find the planted errors.
The remittance exercise deserves a specific example, because it is the one that separates candidates most clearly. Give them a line showing a billed amount of $210.00, an allowed amount of $138.50, a paid amount of $98.80, a contractual adjustment of $71.50 and a patient responsibility of $39.70, and ask three questions: what does the patient owe, why is the adjustment not billable to the patient, and what would you check if the paid amount had been $78.80 instead. A candidate who reasons through it, even slowly, can be taught billing. A candidate who guesses cannot.
A 90-day training plan
The mistake most practices make is putting a new biller next to the existing one and calling it training. The existing biller is overloaded, teaches whatever comes across the desk that day, and the new hire learns fragments. A plan with a sequence and checkpoints is faster.
- Weeks 1 to 2: the foundation. How a visit becomes a claim. The parts of the CMS-1500. CPT, ICD-10-CM and HCPCS at the level of "what each is for". Modifiers 25, 59 and the laterality modifiers. What a clearinghouse does. What an ERA is and how to read CARC and RARC codes. The practice's payer mix and the top ten payers' portals. Structured coursework helps here; a live online RCM course gives a new hire the framework in a couple of weeks that would take months to absorb by osmosis.
- Weeks 3 to 4: payment posting. Post ERAs alongside the trainer, then alone with review. Posting teaches the new biller what payers actually do with claims, which is the best possible preparation for working denials.
- Weeks 5 to 8: rejections and eligibility denials. Start with clearinghouse rejections (missing data, invalid IDs) and eligibility denials (CO-27, CO-31 and the like). These are high volume, low complexity and teach payer phone and portal skills.
- Weeks 9 to 12: authorization, coding and medical necessity denials. Move to CO-197, bundling denials and medical necessity denials with the trainer reviewing each appeal before it goes out. By the end of week 12 the new biller should be handling routine denials independently and escalating the complex ones.
Set checkpoints at 30, 60 and 90 days with specific, observable standards. Vague "how is it going" check-ins do not tell you whether the training is working.
| Checkpoint | The new biller can | Measured by |
|---|---|---|
| Day 30 | Post an ERA batch with no unapplied items; explain any CARC code on it | Trainer review of three batches; unapplied report |
| Day 60 | Resolve 20 clearinghouse rejections a day with under 5% rework; correct eligibility denials without help | Rejection queue counts; rework rate from the trainer's re-check |
| Day 90 | Write an authorization or bundling appeal that needs no corrections; work a payer portal and phone tree unassisted | Three appeals reviewed before sending; call notes in the system |
Realistic productivity
Expect roughly a third of an experienced biller's output at 30 days, half to two-thirds at 60, and close to full on routine work at 90, with complex appeals taking longer. Practices that expect full productivity at 30 days conclude that the hire failed when the plan did. Budget the ramp, and budget the trainer's time too: about a quarter of the senior biller's week for the first month.
The ramp has a cost, and it is worth writing down so nobody is surprised. If a full biller's seat costs the practice about $4,500 a month fully loaded, the first three months produce perhaps $2,500 worth of work for $13,500 of cost, plus the trainer's time. That is the price of the seat being filled in month four instead of never. The alternative, leaving it open, cost the practice in the opening story a doubling of its over-90 AR, which was far more.
Where the practice EHR fits
New billers learn faster when they can practice on a system without breaking live claims. Some practices set up a training database in their practice management system. Others use a dedicated training EHR where a trainee can register patients, code encounters, generate claims and post remittances against fictional data. Either way, the principle is the same: the first fifty claims a new biller touches should not be real ones.
Keeping the people you trained
Training a biller and then losing them at month eight to a hospital paying four dollars an hour more is the most expensive outcome, and it is common. In our experience the practices that keep billers do a few unglamorous things. They pay a market wage and review it annually against actual local postings, not against last year's number. They offer remote or hybrid days once the biller is independent, because that is what the competing employers offer. They give the biller ownership of something specific (a payer, a denial category, the monthly aging report) rather than an undifferentiated queue. They pay for one certification exam and the continuing education to keep it. And they do not make the biller the only person who knows how anything works, because that person is exhausted and leaves.
One more, which is less obvious: they show the biller the results. A biller who sees the over-90 AR fall from 24% to 14% over the six months she has owned the Medicaid queue knows her work mattered. A biller who only ever sees the next item in the queue does not, and is easier to recruit away.
When hiring is the wrong answer
Sometimes the honest answer is that a practice with 1,200 visits a month cannot support a full billing team with backup, training and vacation coverage, and a single biller is a single point of failure whatever you pay. In that case, the comparison to make is between the fully loaded cost of the seat and the cost of an outside billing service with the redundancy built in. Both are valid; what is not valid is leaving the position open for six months while the AR ages.
Questions we hear
Should we require a coding certification for a billing role?
Not for an entry-level biller. Certification is valuable for coders and for billers who grow into denial and appeal work, and paying for it after a year is a good retention tool. Requiring it at hire shrinks an already small pool.
Can we hire remotely?
Yes, and many practices now do, which widens the pool considerably. Remote billers need secure access, a written HIPAA-compliant workspace policy and regular video check-ins during training. Training entirely remotely is harder; where possible, do the first two weeks in the office.
What does a biller need to know about coding?
Enough to recognize when a denial is a coding problem and route it to the coder or the provider, and to understand modifiers well enough to read a bundling denial. A biller does not need to code from the note; a biller does need to know what the codes on the claim mean.
What to do this week
- Rewrite the job posting around the traits above rather than years of experience, and check the wage against three current local postings for comparable roles.
- Build the 30-minute practical test: the registration form with planted errors, the remittance line, the policy paragraph and the role-play.
- Write the 90-day plan with the four phases and the three checkpoints, and block the trainer's time on the calendar for the first month.
- Set up a training database or training EHR so the first fifty claims are not live ones.
- If the seat has been open more than 90 days, price the fully loaded cost of the position against an outside billing service and make a decision either way.
