The Medical Claims/Collections Billing Specialist is responsible for managing outstanding medical accounts, researching and resolving insurance claim issues, and pursuing timely reimbursement from Medicare, Medicaid, commercial insurance carriers, and other payers. This position requires strong knowledge of healthcare collections, insurance claims processing, and payer requirements, with an emphasis on Medicare and Medicaid accounts.

• Manage and work assigned medical collection and A/R queues, prioritizing outstanding, aging, denied, and underpaid claims.
• Perform detailed follow-up on Medicare, Medicaid, and commercial insurance claims to identify payment delays, denials, underpayments, and outstanding balances.
• Review and interpret EOBs, ERAs, payer correspondence, and claim status information to determine appropriate collection and follow-up actions.
• Research claim denials, rejections, payment discrepancies, eligibility issues, authorization requirements, coding issues, and other barriers to reimbursement.
• Identify the reason a claim was not paid and take appropriate action, including correcting and resubmitting claims, contacting insurance carriers, submitting documentation, and initiating appeals when appropriate.
• Conduct timely and persistent insurance collections and A/R follow-up to maximize reimbursement and reduce outstanding balances.
• Utilize payer portals and internal systems to verify claim status, eligibility, benefits, payment information, and outstanding balances.
• Maintain thorough and accurate account documentation, MR notes, status codes, collection activity, and follow-up dates.
• Research exception reports and unresolved accounts and communicate findings and recommended actions to the Revenue Cycle Manager.
• Update patient demographic, insurance, and claim information in internal and external systems to ensure accurate billing and collections.
• Process corrected claims and other billing transactions through applicable billing systems.
• Assist patients with billing questions, account balances, insurance questions, and payment arrangements while providing professional and courteous customer service.
• Process patient payments accurately using the Z-Pay application.
• Identify trends in denials, unpaid claims, and payer issues and communicate recurring problems to management.
• Assist with training staff on Medicare, Medicaid, insurance requirements, collections procedures, claim follow-up, and billing workflows as needed.
• Maintain confidentiality and comply with HIPAA requirements and protection of PHI at all times.

• High School Diploma or equivalent required.
• Minimum of two (2) years of experience in medical accounts receivable, healthcare collections, insurance claims processing, or medical billing.
• Strong working knowledge of Medicare and Medicaid billing, claims processing, reimbursement, and collection procedures preferred.
• Experience working insurance A/R and following up on unpaid, denied, and underpaid claims strongly preferred.

• Strong knowledge of medical insurance billing, claims processing, and healthcare collections.
• Working knowledge of Medicare and Medicaid payer requirements and reimbursement processes.
• Ability to analyze EOBs, ERAs, denial information, and payer correspondence to determine appropriate next steps.
• Strong understanding of A/R aging, claim follow-up, denial resolution, corrected claims, and appeals.
• Excellent attention to detail and accuracy when reviewing claims, account information, and payment activity.
• Ability to manage a high volume of accounts while meeting collection and follow-up deadlines.
• Strong research and problem-solving skills with the ability to identify the root cause of claim and payment issues.
• Professional communication skills when working with patients, Medicare/Medicaid representatives, commercial insurance carriers, and internal staff.
• Proficiency with MS Windows, RIS systems, billing platforms, payer portals, and other healthcare software systems.
• Ability to learn and adapt to multiple software systems and changing insurance requirements.
• Strong written and verbal communication skills.
• Commitment to maintaining HIPAA compliance and protecting PHI.