Job Overview: The Billing Specialist is responsible for managing and processing patient billing, insurance claims, and payments in a healthcare setting. This role involves verifying patient information, submitting claims to insurance companies, following up on unpaid claims, and ensuring accurate patient invoices. The Billing Specialist plays a critical role in maintaining the financial health of the organization by ensuring timely and accurate billing practices and addressing any billing-related issues promptly.

Key Responsibilities:

Patient Billing:

Generate and process patient invoices for medical services provided, ensuring accuracy and compliance with insurance policies.

Verify insurance information, billing codes (CPT, ICD-10), and patient demographics to ensure accurate billing.

Handle patient inquiries related to billing, provide explanations for charges, and address billing discrepancies or concerns.

Process and post patient payments, including co-pays, deductibles, and out-of-pocket expenses.

Assist patients in understanding their financial responsibility and available payment options, including payment plans.

Insurance Claims:

Submit accurate and timely claims to insurance companies for reimbursement of services provided.

Review and ensure that insurance claims are compliant with insurance company guidelines, coding requirements, and reimbursement policies.

Resolve claim denials by investigating the issue, working with insurance carriers, and submitting corrected claims or appeal letters as necessary.

Follow up with insurance companies on unpaid or outstanding claims, ensuring timely resolution.

Coordinate with the prior authorization team to ensure required approvals for services are obtained before submitting claims.

Payment Posting and Reconciliation:

Post payments and adjustments to patient accounts based on insurance and patient payments.

Reconcile discrepancies between patient balances, insurance payments, and the general ledger.

Generate and review reports to ensure all payments are accurately recorded and follow up on any discrepancies.

Ensure that patient accounts are updated regularly to reflect accurate payment status.

Reporting and Documentation:

Maintain accurate records of claims, payments, denials, and patient billing information.

Prepare billing statements and financial reports for internal auditing and review.

Keep track of aged receivables and assist with identifying trends in claim denials or payment delays.

Submit periodic billing reports to management, outlining revenue collected, unpaid claims, and account balances.

Collaboration and Communication:

Work closely with insurance companies, patients, and healthcare providers to resolve billing issues and ensure the timely payment of claims.

Collaborate with the coding team to ensure proper coding of procedures, diagnoses, and services rendered.

Assist in resolving discrepancies between the practice’s billing and the insurance company’s records.

Maintain effective communication with other departments (e.g., front desk, medical assistants) to gather necessary information for accurate billing.

Compliance and Confidentiality:

Ensure compliance with HIPAA and other relevant healthcare regulations when handling patient and billing information.

Stay informed of changes in insurance policies, coding standards, billing procedures, and regulatory requirements.

Maintain patient confidentiality and security of financial information at all times.

Customer Service:

Provide high-level customer service by addressing patient billing inquiries, explaining charges, and offering solutions for outstanding balances.

Assist patients with understanding their insurance coverage and financial responsibilities.

Qualifications:

High school diploma or equivalent required; Associate’s degree in healthcare administration, business, or related field preferred.

Proven experience in medical billing, coding, or healthcare administration, ideally in a clinical or healthcare setting.

Strong knowledge of insurance terminology, medical billing procedures, and coding (CPT, ICD-10, HCPCS).

Experience with electronic health records (EHR) and practice management systems.

Familiarity with healthcare regulations and billing compliance, including HIPAA.

Strong attention to detail and organizational skills.

Excellent written and verbal communication skills.

Ability to handle sensitive and confidential information with discretion.

Strong problem-solving skills, particularly related to billing issues and claims resolution.

Knowledge of insurance verification and claims processes is highly preferred.

Physical Requirements:

Ability to sit for extended periods and work at a desk or computer.

Ability to communicate effectively with patients, insurance representatives, and healthcare providers.

Occasionally required to lift office materials or files.

Work Environment: This position typically works in an office environment, within a healthcare or medical practice. The Billing Specialist will interact with patients, insurance companies, medical staff, and the management team to facilitate billing and payment processes.

Salary and Benefits: Salary is competitive and based on experience. Benefits may include health insurance, paid time off, retirement savings, and professional development opportunities.