Medical Biller

Role Overview

The Medical Billing & Claims Management Specialist ensures the accurate preparation, submission, tracking, and reimbursement of medical claims in compliance with U.S. healthcare regulations. This role supports the full revenue cycle by maintaining accurate coding, processing claims promptly, resolving billing issues, and coordinating effectively with insurance companies, healthcare providers, and internal teams.

Key Responsibilities

1. Claims Preparation and Submission

   • Prepare, review, and submit complete and accurate medical claims to commercial insurance providers, Medicare, and Medicaid.
   • Apply the appropriate ICD-10, CPT, and HCPCS codes based on medical documentation and payer guidelines.
   • Review claims for accuracy and completeness before submission to minimize errors and rejections.

2. Insurance Eligibility and Benefits Verification

   • Verify patient insurance coverage, eligibility, benefits, and authorization requirements.
   • Identify coverage limitations or discrepancies before services are rendered to prevent claim delays and denials.

3. Claims Monitoring and Follow-Up

   • Monitor submitted claims and track their status through insurance portals and billing systems.
   • Follow up proactively on unpaid, underpaid, denied, or delayed claims to support timely reimbursement.
   • Communicate with insurance representatives to clarify claim statuses and resolve outstanding issues.

4. Denial and Rejection Management

   • Review denied or rejected claims and determine the root cause.
   • Correct coding or documentation errors, obtain missing information, and resubmit claims promptly.
   • Assist with claim appeals and maintain accurate records of all follow-up activities.

5. Payment Posting and Account Reconciliation

   • Accurately post payments, adjustments, contractual allowances, and denials to patient accounts.
   • Reconcile payments against remittance advice and identify any payment discrepancies.
   • Maintain accurate and up-to-date billing and financial records.

6. Compliance and Documentation

   • Ensure all billing activities comply with HIPAA, payer policies, and applicable federal and state healthcare regulations.
   • Maintain complete, accurate, and compliant documentation for claims, follow-ups, payments, and billing-related communications.

7. Reporting and Revenue Cycle Support

   • Prepare and analyze reports on claims, collections, denials, reimbursements, and outstanding balances.
   • Identify billing trends, recurring issues, and opportunities to improve revenue cycle performance.
   • Collaborate with healthcare providers and internal teams to resolve documentation and billing concerns.

Qualifications

• Strong knowledge of medical terminology, common diagnoses, procedures, treatment workflows, and medical records; no clinical license required.
• Proven experience in U.S. medical billing, claims processing, or revenue cycle management.
• Proficiency in ICD-10, CPT, and HCPCS coding, with working knowledge of HIPAA and payer-specific billing requirements.
• Experience using medical billing software, EMR/EHR systems, insurance portals, and tools for claim submission, eligibility verification, and payment posting.
• Ability to request, review, and verify medical bills and records for accuracy and completeness.
• Skilled in comparing provider procedure estimates and approved amounts against actual medical bills.
• Strong attention to detail in identifying coding errors, missing documentation, billing discrepancies, and claim inconsistencies.
• Experience researching and resolving denied, unpaid, or underpaid claims and communicating with insurance representatives.
• Highly organized and analytical, with the ability to manage high-volume data efficiently.
• Excellent written and verbal English communication skills, with a professional and collaborative approach.