Medical Collections Representative

Job Description Job Description Job Title: Medical Collections Representative (Full-time; Onsite) Who are we looking for? We are currently seeking a Medical Collections Representative who will play a critical role in ensuring the financial health of the organization by managing patient accounts, verifying eligibility and benefits, and overseeing collections activities. This position focuses on maximizing revenue through accurate account management, proactive follow-up, and effective communication with patients, payors, and internal teams. Additionally, the role emphasizes maintaining compliance with healthcare regulations, delivering exceptional customer service, and supporting efficient billing workflows to enhance operational efficiency and patient satisfaction. Duties and Responsibilities: Eligibility and Benefits Verification: Perform eligibility and benefits inquiries for both new and established patients, as needed. Enter and make the appropriate changes in the EMR/PM system(s) and Salesforce regarding guarantor, payor, insurance eligibility and benefits coverage. Determine and update copayment, coinsurance, deductible, and out-of-pocket amounts. Verify eligibility and benefits using a real-time system response, through health plan portals, and/or via telephone to the health plan and/or guarantor. Responsible for verifying COB information and communicating with the health plan and/or guarantor. Collections: Manage a portfolio of assigned accounts that are aged in a timely manner. Maximize revenue by providing appropriate follow-up and document actions taken. Ability to read and interpret an explanation of benefits. Knowledge of a CMS-1500 claim form and field requirements. Effective appeal writing skills to submit claim appeals with supporting documentation per payor policy/guidelines. Monitor and maintain revenue integrity through appropriate account adjustments, small balance write-off and payment reconciliations. Reconcile customer disputes as they pertain to payment of outstanding balances. Respond to correspondence timely. Heavy telephone contact to ensure timely follow-up and account resolution, and customer service phone coverage. Daily productivity standards and quality standards must be met. Manage credit balances and refunds. Document instructions for the RCM team in the EMR/PM system(s) and Salesforce. Respond to and resolve patient statement and claim tickets via Salesforce. Respond to emails and phone calls related to patient statements and claims. Performs job duties with oversight. Other duties as assigned. General: Collaborate with patients or customers, third party institutions and other team members to research and resolve billing inconsistencies and errors. Collect and maintain patient demographic and medical information required for medical billing. Ensure patient documentation is scanned and filed correctly within the Electronic Medical Record (EMR). Provide exceptional customer service. Maintain and understand various medical billing software platforms. Navigate insurance websites and answers customer inquiries. Understand office visit fees including procedure and diagnosis codes. Maintain confidentiality and adhere to HIPAA regulations. Complete assigned tickets as required. Adhere to policies and procedures, update of forms and manuals. Assist in development and communication of SOP for key areas to improve accuracy and understanding of processes. Support daily, weekly, and monthly medical billing metrics. Identify issues and present possible solutions and/or suggestions to management. Interfaces with other departments to resolve medical billing workflows. Assist other staff and support the team approach. Communicate appropriately and clearly to management, co-workers, and physicians. Maintain all reference material that is provided by the supervisor, manager, or director. Know and follow the Employee Handbook policies and procedures. Maintain patient confidentiality so that HIPAA compliance is always observed. Demonstrate honesty and integrity in everyday activities. Arrive to work on time. Consistently be at work. Willingness to work overtime when requested. Other duties as assigned. Qualifications: . High School diploma or GED required Customer Service experience required Medical billing and coding certification preferred. 3+ years of experience in medical billing required 3+ years of experience in inpatient/outpatient collections with a specialty group practice, with strong emphasis on appeals/underpayment collection activities. Experience with out-of-network payors. Comfortable navigating across various computer systems to locate critical information. Knowledge of insurance policies/guidelines, EOB (Explanation of Benefits), prior authorization/referral processes, medical terminology, CPT/ICD/HCPCS coding preferred. Experience with payor portals and affiliates. Experience with EMR and PM systems (Athena, AdvancedMD a plus) Experience using Salesforce a plus Must have strong analytical skills, proficient with spreadsheets Knowledge of health networks, IPA, HMO, PPO and contract affiliations Proficiency in meeting deadlines and prioritize workload. Ability to work independently, with direction, and as part of a team. Exceptional organizational, presentation, and communication skills, both verbal and written Experience with Microsoft Office Suite Self-motivated, team-oriented, very responsible, and focused on exceeding customer expectations. About Us The Translational Pulmonary & Immunology Research Center (TPIRC) is at the forefront of medical innovation, committed to transforming the treatment of rare and orphan diseases. Our center integrates cutting-edge diagnostic tools, artificial intelligence, and patient-centered research to push the boundaries of care and outcomes. As a non-profit research and clinical care center, TPIRC specializes in developing innovative, personalized treatment protocols for rare and orphan diseases. Our commitment to precision medicine allows us to create tailored treatment plans by meticulously analyzing each patient’s unique lab results, medical history, and symptoms. This personalized approach ensures that our highly skilled clinicians can devise the most effective strategies for each individual. Our advanced methodology not only addresses complex medical challenges but also generates critical data. By examining millions of data points, we uncover novel findings and drive research advancements across five key areas of focus. This approach solidifies TPIRC's position as a leader in pioneering treatment solutions and advancing patient care. Why Join TPIRC? At TPIRC, you will be part of a vibrant and forward-thinking organization that is passionate about making a difference. We cultivate a collaborative atmosphere where innovative ideas are encouraged and every team member’s role is crucial to our mission. Our work is profoundly impactful, and you will witness firsthand how your contributions support our transformative goals. Employee Benefits We offer a comprehensive benefits package, including competitive salary, 401(k) with employer match, medical, dental, and vision insurance, generous paid time off, company-paid holidays, and sponsored employee events. We are also committed to your professional development with individualized training and career growth opportunities. Physical requirements: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms. The employee is required to walk between multiple office locations that include the use of stairs (elevator is only available in some instances). This position requires the ability to occasionally lift office products and supplies, up to 20 pounds. The company provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, marital status, veteran status, or any other consideration made unlawful by federal, state, or local laws. The company is committed to providing reasonable accommodation for qualified applicants, and employees with disabilities to ensure they enjoy equal access to all employment opportunities and benefits of employment as required by the Americans with Disabilities Act.