Summary

The Medical Billing Specialist is responsible for managing third-party billing and collections activities to ensure the timely and accurate submission, processing, and resolution of medical and pharmacy claims. This role reviews and bills medical and NCPDP claims, identifies and resolves claim rejections and billing discrepancies, and works to maximize reimbursement. The ideal candidate has experience with home infusion billing, payer reimbursement guidelines, and medical billing practices, along with strong analytical, communication, and problem-solving skills. Attention to detail, the ability to work independently, and proficiency with Microsoft 365 are essential.

Essential Duties & Responsibilities

• Manage third-party billing and collections activities.
• Ensure the timely and accurate submission of claims.
• Meet quality assurance standards, productivity goals, and performance benchmarks.
• Identify and update patient and insurance information changes.
• Process home infusion and nursing claims.
• Review and resolve NCPDP claim rejections, including resubmissions and appeals as appropriate.
• Analyze billing trends and identify opportunities for process improvement.
• Maintain accurate documentation and records.
• Perform other duties as assigned.

Knowledge, Skills & Abilities

• Strong verbal and written communication skills with patients, payers, external agencies, and internal stakeholders.
• Professional, courteous, and customer-focused approach.
• Ability to interpret and apply instructions received through various communication methods.
• Knowledge of home infusion services and related billing practices.
• Understanding of insurance policies, payer requirements, and reimbursement processes.
• Knowledge of medical billing methodologies and reimbursement regulations.
• Ability to maintain confidentiality and handle sensitive information with discretion.
• Strong organizational skills with excellent attention to detail.
• Ability to manage multiple priorities in a fast-paced environment.
• Basic mathematical proficiency, including addition, subtraction, multiplication, and division.
• Strong problem-solving, time management, and critical-thinking skills.
• Ability to work independently and collaboratively within a team environment.
• Knowledge of ICD-10, CPT, HCPCS codes, and medical terminology preferred.
• Proficiency with Microsoft 365 applications.
• Experience with HCN 360 and/or CPR+ preferred.
• Working knowledge of Medicare billing requirements, including DME MAC guidelines preferred.

Minimum Qualifications

• High school diploma or GED required.
• One to three years of related billing, collections, or healthcare revenue cycle experience.
• Experience in a medical, healthcare, or home infusion environment preferred.
• Experience with medical billing and administrative record management.
• Strong customer service and interpersonal skills.
• Excellent organizational, communication, and problem-solving abilities.

Preferred Qualifications

• Home infusion billing or collections experience.
• Experience billing both medical and pharmacy claims.
• Familiarity with Medicare, commercial payers, and reimbursement regulations.
• Experience working with claim denials, appeals, and reimbursement resolution.