Accounts Receivable (AR) Specialist

The Hospital Accounts Receivable (AR) Specialist is responsible for managing hospital patient accounts, following up on outstanding insurance claims, resolving claim denials, and ensuring timely reimbursement for hospital services. The role involves reviewing unpaid and underpaid claims, investigating billing discrepancies, communicating with insurance companies, and coordinating with hospital departments to resolve accounts receivable issues.

The ideal candidate has a strong understanding of hospital revenue cycle management, medical billing, insurance reimbursement, and claims follow-up processes. The primary objective is to reduce outstanding accounts receivable, improve cash flow, minimize denials, and ensure compliance with hospital policies and healthcare regulations.

Key Responsibilities

1. Accounts Receivable Management

• Review and manage outstanding hospital accounts receivable to ensure timely payment from insurance companies and other responsible parties.
• Analyze AR aging reports and prioritize accounts based on aging, outstanding balance, payer requirements, and timely filing limits.
• Follow up on unpaid, partially paid, and delayed hospital claims.
• Monitor accounts in 30-, 60-, 90-, and 120-plus-day aging categories.
• Identify accounts requiring additional documentation, corrections, appeals, or escalation.
• Maintain accurate account notes and document all follow-up activities in the hospital billing system.

2. Insurance Claim Follow-Up

• Contact commercial insurance companies, Medicare, Medicaid, and other healthcare payers to verify claim status and payment information.
• Investigate rejected, denied, and pending claims to determine the reasons for nonpayment.
• Review claim processing timelines and take appropriate action to expedite reimbursement.
• Submit corrected claims and supporting documentation when required.
• Follow up with payer representatives until claims are resolved and payments are received.
• Escalate complex or high-value accounts to the appropriate supervisor or manager.

3. Denial Management and Appeals

• Identify and analyze claim denials related to eligibility, authorization, medical necessity, coding, documentation, and payer policy.
• Review Explanation of Benefits (EOBs) and Electronic Remittance Advice (ERAs) to determine denial reasons and adjustment details.
• Prepare and submit appeals, reconsiderations, and corrected claims within payer deadlines.
• Coordinate with coding, utilization review, case management, patient registration, and clinical departments to resolve denial issues.
• Track denial trends and recommend corrective actions to reduce recurring denials.
• Ensure timely follow-up on appealed claims until a final determination is received.

4. Hospital Billing and Reimbursement

• Review hospital claims for inpatient and outpatient services, including facility charges and applicable ancillary services.
• Understand hospital billing workflows, including UB-04/CMS-1450 institutional claims and electronic 837I submissions.
• Review patient account information, insurance coverage, authorization details, and billing documentation as needed.
• Investigate underpayments and discrepancies between expected reimbursement and actual payments.
• Verify contractual adjustments and identify potential reimbursement variances.
• Coordinate with billing and coding teams to correct claim errors and prevent future payment delays.

5. Payment Posting and Account Reconciliation

• Review payment information and adjustment details to identify discrepancies in account balances.
• Coordinate with payment posting teams to resolve unapplied payments, incorrect adjustments, and reconciliation issues.
• Identify duplicate payments, missing payments, and potential overpayments for appropriate review.
• Ensure outstanding balances accurately reflect payments, contractual adjustments, and other approved account transactions.
• Support reconciliation of payer accounts and financial reports as required.

6. Communication and Coordination

• Communicate professionally with insurance company representatives, third-party administrators, and internal hospital departments.
• Collaborate with patient access, registration, billing, coding, case management, utilization review, and finance teams.
• Request medical records, authorization information, itemized bills, and other supporting documents when necessary.
• Respond to account-related inquiries and resolve billing issues within established service standards.
• Maintain clear and complete documentation of payer communications and account resolutions.

7. Compliance and Reporting

• Follow HIPAA privacy and security requirements and applicable healthcare billing regulations.
• Adhere to payer contracts, reimbursement policies, hospital procedures, and timely filing requirements.
• Prepare AR aging reports, denial reports, collection reports, and account status updates.
• Meet established productivity, quality, accuracy, and collection targets.
• Participate in revenue cycle improvement initiatives and process audits.

Qualifications and Requirements

• High school diploma or equivalent required; an associate or bachelor's degree in healthcare administration, finance, accounting, or a related field is preferred.
• Previous experience in hospital medical billing, accounts receivable, insurance follow-up, or revenue cycle management is preferred.
• Knowledge of hospital inpatient and outpatient billing processes.
• Familiarity with Medicare, Medicaid, commercial insurance, managed care plans, and third-party payers.
• Understanding of institutional billing forms, UB-04, 837I electronic claims, EOBs, ERAs, and claim adjustment codes.
• Basic understanding of ICD-10-CM/PCS, CPT, HCPCS, medical necessity, prior authorization, and reimbursement guidelines.
• Experience using hospital information systems, electronic health records (EHRs), and patient accounting or practice management software.
• Proficiency in Microsoft Excel and basic reporting tools.
• Knowledge of HIPAA and healthcare compliance requirements.

Required Skills and Competencies

• Strong analytical and problem-solving skills.
• Excellent verbal and written communication skills.
• High attention to detail and accuracy.
• Ability to manage high-volume accounts and meet productivity targets.
• Strong organizational and time-management skills.
• Ability to prioritize aging accounts and time-sensitive appeals.
• Effective follow-up and negotiation skills when communicating with insurance payers.
• Ability to work independently and collaboratively with multidisciplinary hospital teams.
• Commitment to confidentiality, ethical conduct, and continuous improvement.

Benefits:

• Bonus Compensation
• Health Insurance
• Paid time off plan (Vacation, Holidays, etc.)
• 401(k) savings plans.
• Life Insurance.