Medical Billing Specialist

Job Description

Job Description

Medical Billing Specialist

Department: Revenue Cycle Management
Reports To: Director of Revenue Cycle Management
Position Type: Full-Time
Work Environment: Office-Based Setting

Position Summary

The Medical Billing Specialist is an experienced, hands-on member of the Revenue Cycle Management team responsible for supporting the Director of Revenue Cycle Management in the day-to-day billing and collections functions of the practice.

This position is intended for an individual with a strong working knowledge of medical billing who can independently manage assigned accounts, identify billing issues, work denials, follow up on outstanding claims, prepare resubmissions and appeals, and assist in maximizing appropriate reimbursement from commercial and government payers.

The ideal candidate will have experience working within a physician's office, outpatient medical practice, specialty practice, or medical billing company. Experience in a smaller, fast-moving healthcare environment is particularly valuable, as the position requires adaptability, organization, independent problem-solving, and direct communication with clinical and administrative team members.

This role will work closely with and under the direction of the Director of Revenue Cycle Management. The Medical Billing Specialist is expected to possess greater experience and independent billing capability than an entry-level or general biller, while escalating complex reimbursement, coding, contractual, and revenue-cycle matters to the Director or appropriate senior RCM personnel.

Essential Duties and Responsibilities

Claims Management & Follow-Up

• Review and follow up on outstanding insurance claims to facilitate timely and accurate reimbursement.

• Work assigned accounts receivable and identify claims requiring additional action.

• Investigate unpaid, underpaid, rejected, or otherwise unresolved claims.

• Contact insurance carriers as necessary to determine claim status and identify outstanding requirements.

• Correct billing errors and prepare claims for timely resubmission.

• Monitor previously corrected or resubmitted claims through resolution.

• Assist with identifying recurring billing issues and communicate trends to the Director of Revenue Cycle Management.

• Maintain accurate documentation of billing activity, payer communications, claim status, and follow-up actions.

Denials & Appeals

• Review insurance denials and determine the appropriate next steps for resolution.

• Identify denial reasons, including coding issues, authorization problems, eligibility concerns, filing limitations, medical necessity issues, documentation requests, and payer processing errors.

• Correct and resubmit claims when appropriate.

• Prepare first-level appeals and supporting documentation in accordance with payer requirements.

• Follow appeals through resolution and perform additional follow-up as necessary.

• Escalate complex, high-dollar, recurring, or unusual denials to the Director of Revenue Cycle Management.

• Assist the Director in identifying denial patterns that may require changes to front-end workflows, documentation, authorization processes, or billing practices.

Collections & Accounts Receivable

• Perform consistent follow-up on outstanding accounts receivable.

• Prioritize accounts based on aging, balance, payer requirements, filing deadlines, and other relevant factors.

• Work directly with commercial insurance carriers, Medicare, Medicaid, and other applicable payers to resolve outstanding balances.

• Research payment discrepancies, underpayments, and unexplained adjustments.

• Assist with recovering appropriately billable and collectible balances.

• Identify accounts requiring additional documentation, corrected claims, appeals, or senior-level intervention.

• Maintain organized and timely follow-up to prevent avoidable aging of receivables.

Coding & Billing Knowledge

• Maintain a working understanding of CPT, ICD-10-CM, modifiers, and other coding concepts necessary to accurately review and troubleshoot claims.

• Recognize common coding or claim-configuration issues that may contribute to denials or reduced reimbursement.

• Review claims for basic billing accuracy prior to submission or resubmission.

• Apply appropriate payer-specific billing requirements within the scope of the position.

• Communicate suspected coding or documentation issues to the Director of Revenue Cycle Management or appropriate clinical personnel rather than independently making unsupported coding determinations.

• Remain current on billing requirements and common payer changes affecting assigned responsibilities.

Insurance & Payer Knowledge

The Medical Billing Specialist should possess a practical working knowledge of:

• Commercial insurance plans

• Medicare

• Medicaid and Medicaid Managed Care plans

• Primary and secondary insurance coordination

• Eligibility and benefit considerations affecting claims

• Prior authorization and referral requirements as they relate to reimbursement

• Explanation of Benefits (EOBs) and Electronic Remittance Advice (ERAs)

• Timely filing requirements

• Claim adjustment and denial codes

• Appeals and reconsideration processes

• Basic coordination of benefits requirements

Revenue Cycle Support

• Serve as a reliable operational resource to the Director of Revenue Cycle Management.

• Assist with billing projects, account reviews, payer follow-up initiatives, and revenue-cycle clean-up efforts as assigned.

• Research individual accounts and provide clear summaries of identified issues and recommended next steps.

• Communicate with scheduling, authorization, eligibility, clinical, and administrative personnel when information is required to resolve a claim.

• Assist in identifying workflow gaps that contribute to billing delays, denials, or lost revenue.

• Provide coverage for routine revenue-cycle responsibilities during periods of increased volume or staff absence.

• Maintain confidentiality and comply with HIPAA and applicable practice policies at all times.

Qualifications Required

• Minimum of 3 years of medical billing, accounts receivable, or related revenue-cycle experience preferred.

• Prior experience in a physician's office, outpatient medical practice, specialty practice, or medical billing company strongly preferred.

• Demonstrated experience working insurance denials, collections, claim follow-up, corrected claims, and resubmissions.

• Experience preparing or assisting with insurance appeals.

• Working knowledge of CPT and ICD-10-CM coding concepts.

• Familiarity with commercial insurance, Medicare, and Medicaid billing.

• Ability to interpret EOBs, ERAs, denial codes, and payer correspondence.

• Strong attention to detail and ability to independently research and resolve routine billing problems.

• Strong written and verbal communication skills.

• Ability to organize and prioritize a high volume of open accounts and follow-up responsibilities.

• Comfortable working within electronic medical record, practice-management, payer portal, and Microsoft Office systems.

Preferred

• Experience within a specialty physician practice, procedural practice, vascular practice, interventional practice, or other outpatient procedural environment.

• Experience with surgical or procedure-based billing.

• Familiarity with medical necessity requirements, prior authorization workflows, and documentation requirements associated with procedural claims.

• Experience working across multiple commercial and government payers.

• Experience within a smaller medical practice or billing organization where employees are expected to manage responsibilities independently rather than within narrowly separated hospital billing departments.

Skills & Competencies

The successful candidate should demonstrate:

• Strong medical billing fundamentals

• Persistence in resolving unpaid and denied claims

• Analytical and investigative ability

• Attention to detail

• Sound judgment regarding when to independently resolve an issue and when to escalate

• Organization and consistent account follow-up

• Professional communication with insurance representatives and internal staff

• Ability to identify patterns rather than treating every denial as an isolated event

• Ability to work independently while remaining responsive to departmental priorities

• Flexibility in a fast-paced outpatient practice environment

• Accountability for assigned work through final resolution whenever reasonably possible

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