Job summary
The Billing and Authorization Specialist is responsible for managing all aspects of the billing and collections processes, with a special focus on securing insurance authorizations and negotiating payment for outstanding claims. This role ensures the financial health of the organization by maximizing revenue and minimizing accounts receivable, while providing superior customer service to patients.
Essential duties and responsibilities
Authorization management: Verify insurance benefits and eligibility, and obtain pre-authorizations for all diagnostic imaging, procedures, and treatments. Respond to insurance inquiries regarding authorization and appeal denied authorizations as needed.
Claims processing: Prepare, review, and submit clean medical claims to various insurance companies and government payers in a timely and accurate manner. Resolve claim rejections and payer edits to ensure successful processing.
Denial and appeal management: Investigate and resolve claim denials, identifying root causes and implementing corrective actions. Prepare and submit appeals with compelling evidence and documentation.
Claims negotiation: Negotiate payment with insurance companies for denied or underpaid claims. Act as a patient advocate to negotiate payment plans for large balances and resolve complex billing issues.
Accounts receivable (A/R) management: Conduct timely follow-ups with insurance carriers on unpaid claims. Review and manage aging reports to prioritize and work outstanding accounts.
Communication: Communicate effectively with patients, insurance companies, and clinical staff to ensure proper billing and address patient inquiries regarding coverage, balances, and payment options.
Compliance and documentation: Maintain thorough documentation of all billing, authorization, and collection activities. Ensure all practices adhere to HIPAA regulations and other compliance standards.
System management: Utilize electronic health record (EHR) and practice management software to enter charges, post payments, and maintain accurate billing records.
Qualifications and skills
- Experience: A minimum of 2–3 years of experience in medical billing and collections, including specific experience with authorization and denial management.
- Knowledge: In-depth understanding of medical billing procedures, coding systems (ICD-10, CPT), and payer-specific guidelines. Familiarity with navigating insurance payer portals is essential.
- Communication skills: Exceptional verbal and written communication skills for professional and effective interaction with internal staff, patients, and insurance representatives.
- Technical proficiency: Strong computer skills and experience with medical practice management systems and EHR software.
- Analytical skills: Strong problem-solving and analytical abilities to investigate and resolve complex billing issues.
- Personal attributes: High attention to detail, excellent organizational and time management skills, and the ability to work independently and as part of a team.
- Certifications (preferred): Certified Professional Biller (CPB) or Certified Coding Specialist (CCS) credentials are a plus.
