Medical Billing and Collections Representative (Commercial)

JOB TITLE: Medical Billing & Collections Representative (Commercial)
COMPANY: Progressive Billing
PAY RANGE: OPM Pay Grade 7 (Hourly)
FLSA Status: Non-Exempt

SUMMARY: The Medical Billing & Collections Representative is responsible for managing the full lifecycle of the billing and collections process for professional medical claims, specializing in commercial insurance carriers and out-of-network (OON) reimbursement.


This position focuses on ensuring accurate claim submission, timely payments, and effective resolution of denials and underpayments, particularly for Neuro Spine Surgery, Orthopaedic, and Podiatry services.


The ideal candidate will bring strong analytical, negotiation, and communication skills with a solid understanding of payer policies and surgical coding.

PRIMARY DUTIES AND RESPONSIBILITIES (but not limited to):

Collections & Follow-up
Monitor and follow up on unpaid or underpaid claims from commercial and OON
carriers, focusing on high-value surgical claims.
Communicate with insurance carriers, providers, and patients to ensure prompt and
accurate claim resolution.
Research and appeal denials, including complex procedure denials, ensuring timely
and compliant follow-up.
Collaborate with internal teams to verify accurate coding and claim documentation
for surgical procedures. Dispute Resolution
Investigate and resolve OON reimbursement discrepancies to ensure fair and compliant payments.
Negotiate reimbursements with insurance carriers and third-party negotiators for complex or high-cost surgeries.
Maintain up-to-date knowledge of high-frequency surgical CPT codes, payer policies, and current reimbursement trends.

Patient Communication
Provide clear and professional explanations of patient statements, surgical charges,
and OON responsibilities.
Assist patients with setting up payment plans and answering billing-related
questions. Documentation & Reporting
Maintain accurate records of all billing and collection activities for assigned specialties.
Generate detailed reports on outstanding claims, denials, appeals, and payment trends for management review.

Insurance Reconciliation
Reconcile received payments against submitted claims to ensure proper
reimbursement.
Process adjustments, refunds, and write-offs per company policies and payer
guidelines.

QUALIFICATIONS:

Experience
35 years of medical billing and collections experience, specializing
in commercial insurance and out-of-network billing.
Prior experience in Neuro Spine, Orthopedic, or Podiatry billing required.
Strong understanding of ICD-10, CPT, and HCPCS coding principles.
In-depth knowledge of OON reimbursement structures, EOB interpretation, and
payer dispute processes. Technical Proficiency
Experience with medical billing and EHR/claims management software.
Proficient in MS Excel and reporting tools.
Knowledge of HIPAA compliance and best practices for data security.

Communication Skills
Excellent written and verbal communication for interactions with carriers, patients,
and providers.
Strong negotiation and conflict-resolution skills.

Problem-Solving
Analytical and detail-oriented approach to identifying and resolving claim
discrepancies.
Ability to prioritize and manage multiple tasks in a fast-paced environment.

Education
High school diploma or equivalent required.
Associates or Bachelors degree in Healthcare Administration, Business, or related
field preferred.

PHYSICAL DEMANDS AND WORK ENVIRONMENT:
This is an office-based position with standard working hours from Monday through Friday. Occasional overtime may be required to meet deadlines or address urgent claim issues. The role operates within a collaborative team environment that offers opportunities for professional growth and advancement.

The above is intended to describe the general content of and requirements for the performance of thisjob. It is not to be construed as an exhaustive statement of duties, responsibilities, or physical requirements. Nothing in this job description restricts managements right to assign or reassign duties and responsibilities to this job at any time. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

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