MEDICARE SPECIALIST (Medicare Billing)

Job Description

Job Description

Description:

Position Overview

This position collaborates with global and domestic cross-functional teams (order to cash), including Intake, Customer Care, and Billing, to resolve patient questions, concerns, and issues related to Medicare coverage, claims, denials, and patient responsibility. Responsibilities include inbound and outbound calls, insurance verification & payer change, invoice review, appeals and denial resolution, payment processing, and interpretation of claims and EOBs, all within a compliant, audit-ready framework.

This position operates in a call queue environment and serves as the primary point of contact for inbound patient billing inquiries within the Revenue Cycle Management (RCM) team, with a strong focus on Medicare-related billing, eligibility, and claims resolution. The role is responsible for delivering a high level of patient support while ensuring compliance with Medicare guidelines, CMS requirements, and DMEPOS billing standards.

Key Responsibilities

• Handle high-volume inbound and outbound calls related to Medicare billing statements, coverage, payment plans, and coordination of benefits (COB)
• Accurately document all patient interactions, including inquiries, complaints, and resolutions, ensuring compliance with Medicare and internal documentation standards
• Interpret EOBs and explain Medicare patient responsibility, coverage limitations, and claim outcomes
• Verify insurance eligibility, benefits, and coverage through payer portals, with a focus on Medicare qualification and active coverage
• Review and recalculate invoices as needed to ensure alignment with Medicare billing rules and reimbursement guidelines
• Manage and resolve denials and appeals, ensuring proper documentation and adherence to Medicare requirements for medical necessity and claims processing including Medicare audits.
• Request and validate clinical documentation, prescriptions, and supporting records required to meet Medicare medical necessity standards
• Identify and document compliance or non-compliance with treatment requirements, as applicable to Medicare coverage criteria
• Coordinate with internal teams to ensure claims are clean, accurate, and ready for submission or resubmission
• Respond to patient communications across multiple channels, including phone, email, portal, and fax
• Route complex issues to appropriate teams while maintaining ownership of resolution
• Ensure adherence to HIPAA, confidentiality, and Medicare compliance requirements at all times
• Follow up on open tasks, worklists, and outstanding issues in a timely manner
• Support equipment recovery processes when treatment ends or Medicare benefits terminate
• Maintain knowledge of Medicare billing, reimbursement guidelines, and DMEPOS requirements
• Identify trends and escalate training or process improvement opportunities
• Perform other duties and special projects as assigned
• Developing standard operating procedures for Medicare Order-to Cash.

Qualifications

• Minimum of 2 years of customer service experience, preferably in a role emphasizing ownership of the customer or patient financial experience
• Minimum of 2 year of experience in healthcare, with extensive expertise to Medicare billing, RCM, or DMEPOS environments preferred
• Understanding of healthcare terminology, with working knowledge of Medicare claims, EOBs, and patient responsibility
• Strong customer service, problem-solving, and critical thinking skills, with the ability to navigate Medicare-related billing and coverage questions
• Ability to manage high-volume inbound calls and communications while maintaining accuracy and compliance
• Strong verbal and written communication skills, with the ability to explain Medicare billing, coverage, and denials in a clear and professional manner
• High attention to detail, with the ability to identify and correct errors related to claims, documentation, and billing accuracy
• Ability to multitask, prioritize, and follow through in a fast-paced, metrics-driven environment
• Self-starter with the ability to work independently and collaboratively across teams
• Flexible and adaptable to changing business needs, particularly in a growing Medicare-focused operation
• Proficiency in billing systems and Microsoft Office 365; experience with Brightree or similar DME billing platforms preferred