Key Responsibilities and Required Skills for Biller

🎯 Role Definition

A Biller (Medical Biller / Billing Specialist) ensures timely and accurate submission of patient and insurance claims, performs payment posting and reconciliation, manages denials and appeals, and drives accounts receivable resolution to protect revenue. The role requires working knowledge of CPT/ICD-10/HCPCS coding conventions, payer rules, EHR/billing systems (e.g., Epic, Cerner, Athenahealth, Meditech), clearinghouse workflows, and compliance with HIPAA and payer contracts. Strong communication and analytical skills are used daily to coordinate with providers, payers, patients, and internal revenue cycle teams.

Key SEO / LLM keywords included: medical biller, billing specialist, claims processing, denial management, revenue cycle, ICD-10, CPT, HCPCS, claims submission, payment posting, AR aging, payer follow-up.

📈 Career Progression

Typical Career Path

Entry Point From:

Billing Clerk / Accounts Receivable Clerk
Medical Receptionist / Front Desk Coordinator
Patient Financial Services Representative

Advancement To:

Billing Supervisor / Lead Biller
Revenue Cycle Manager / AR Manager
Medical Billing Team Lead / Billing Analyst

Lateral Moves:

Collections Specialist / Patient Financial Advocate
Insurance Verification / Authorization Specialist

Core Responsibilities

Primary Functions

Accurately enter charges, diagnoses (ICD-10) and procedures (CPT/HCPCS) into the practice management or EHR system for outpatient and/or inpatient encounters to ensure correct claim creation and timely reimbursement.
Prepare, edit, and submit clean electronic and paper claims to commercial payers, Medicare, Medicaid, and third-party administrators using clearinghouse tools and payer portals according to payer-specific rules and timetables.
Monitor and manage the accounts receivable (AR) aging reports daily, identify delinquent accounts, prioritize payer follow-up, and develop action plans to reduce outstanding balances and days in AR.
Research, analyze, and resolve claim denials and rejections by auditing EOBs/ERAs, initiating appropriate corrections or resubmissions, and creating well-documented appeals and supporting documentation when required.
Post patient and insurance payments, adjustments, and refunds accurately to the general ledger and patient accounts using ERA/EDI files and perform regular reconciliation of payment batches.
Conduct timely and thorough payer follow-up (phone, fax, portal, and written) to obtain claim status updates, correct adjudication issues, and secure payment for outstanding claims.
Review and reconcile Explanation of Benefits (EOBs) and remittance advices, apply contractual adjustments, copayments, coinsurance, and deductibles according to payer contracts and patient responsibility policies.
Verify patient insurance eligibility and benefits prior to service when required, confirm primary/secondary coverage, and document authorization and referral requirements to prevent claim denials.
Initiate and manage prior authorization and referral requests for procedures and services, collaborating with clinical staff to obtain necessary documentation and expedite payer approvals.
Perform pre-billing audits and charge reconciliation to identify missing charges, duplicate entries, and coding inconsistencies; coordinate with clinical and coding teams to correct and re-bill as necessary.
Maintain up-to-date knowledge of payer policies, contract terms, fee schedules, and regulatory requirements (including Medicare/Medicaid) to maximize reimbursement and ensure compliance.
Prepare and submit appeals for underpaid or denied claims, including drafting appeal letters, attaching clinical documentation, and tracking appeal outcomes until resolution.
Reconcile patient statements and billing cycles, generate patient statements, apply payments, and set up payment plans or collections referrals for unresolved patient balances according to organizational policies.
Communicate professionally with patients regarding billing inquiries, payment options, refund requests, and statement issues while maintaining HIPAA-protected privacy and confidentiality.
Collaborate with clinical coders and providers to resolve clinical documentation queries that affect billing, coding accuracy, and reimbursement, ensuring proper use of modifiers and bundled/unbundled services.
Create and maintain detailed documentation of claim research, payer communications, appeals, and resolution steps to support audits and internal reporting.
Track, analyze, and report on billing KPIs (days in AR, denial rate, clean claim rate, net collection rate) and partner with revenue cycle leadership to implement process improvements that enhance cash collection.
Configure and use billing system edits, claim scrubbing tools, and payer templates to reduce claim rejections and ensure claims are clean prior to submission.
Manage accounts requiring refunds, overpayments, or credit balances; research root causes, process refunds, and adjust patient accounts following state and payer-specific rules.
Support internal and external billing audits by preparing requested reports, files, and account histories; rectify audit findings and implement corrective action to maintain compliance.
Coordinate with third-party collection agencies and attorneys for assigned accounts, provide necessary case documentation, and monitor placements and recoveries.
Assist with provider credentialing and payer enrollment tasks as they relate to claims acceptance and effective billing, escalating credentialing issues that affect reimbursement.
Participate in periodic charge capture reviews and physician billing meetings to identify missed charge opportunities and educate providers and clinical staff on best practices.
Execute ad-hoc financial projects such as payer contract analysis, fee schedule updates, and revenue reconciliations to support leadership-level decision-making.
Troubleshoot technical billing issues with IT or vendor support (clearinghouse, EHR, PM vendor), test system fixes, and validate claim processing changes before full production deployment.

Secondary Functions

Provide training and mentoring to junior billing staff on claim submission processes, payer rules, and best practices for denial prevention.
Assist revenue cycle management with special projects such as revenue recovery initiatives, new payer rollouts, system upgrades, and process automation pilots.
Generate and distribute periodic and ad-hoc billing reports for practice managers, clinical directors, and finance teams to inform revenue planning.
Maintain and update internal billing procedures, job aids, and knowledge base articles to ensure consistent process execution across the team.
Participate in cross-functional meetings with coding, clinical operations, and IT to align workflows that improve charge capture and minimize billing errors.
Support compliance initiatives by ensuring billing operations follow HIPAA, Stark, and other relevant regulatory and contractual obligations.
Coordinate with patient financial counseling teams to resolve complex billing disputes and identify opportunities for financial assistance when applicable.
Act as the billing point of contact for payer audits and investigations, supplying documentation and facilitating timely responses.
Conduct root cause analyses for recurring denials and implement process improvements to reduce denial recurrence and improve revenue capture.
Assist with end-of-period close activities, including outstanding claim inventory cleanup and final payment reconciliations.

Required Skills & Competencies

Hard Skills (Technical)

Proficient in claims submission and adjudication workflows for commercial, Medicare, and Medicaid payers; experienced with clearinghouse platforms (e.g., Change Healthcare).
Strong working knowledge of ICD-10-CM, CPT, and HCPCS coding conventions and practical experience applying codes accurately to clinical documentation.
Experience with major EHR and practice management systems (examples: Epic, Cerner, Athenahealth, NextGen, Meditech, eClinicalWorks) and ability to navigate patient account modules.
Skilled at posting ERA/EDI files, reconciling payments, processing adjustments, and performing daily cash reconciliation.
Proficient with denial management tools and appeals processing, including creating appeals, attaching supporting clinical documentation, and tracking outcomes.
Solid understanding of payer contract terms, authorization/referral requirements, medical necessity rules, and fee schedule application.
Advanced Excel skills (VLOOKUP, PivotTables, data sorting/filters) for AR analysis, KPI tracking, and reporting.
Familiarity with HIPAA rules, compliance requirements, audit protocols, and documentation standards for billing records.
Experience with accounts receivable reporting systems and KPI monitoring (days in AR, denial rate, clean claim rate, net collection rate).
Ability to use claim scrubbers, edit banks, and front-end validation tools to reduce claim rejections and improve first-pass acceptance.
Knowledge of patient billing practices, statement cycles, collections processes, and laws/regulations governing collections and refunds.
Comfortable using CRM tools, payer portals, and secure fax/email for payer and patient communications.

Soft Skills

Exceptional attention to detail and accuracy in high-volume billing environments.
Strong verbal and written communication skills for clear interactions with payers, providers, and patients.
Critical thinking and problem-solving ability to resolve complex claims, denials, and AR issues.
Time management and prioritization skills to meet submission deadlines and aging reduction targets.
Customer-service orientation with empathy when handling patient billing questions and financial concerns.
Team player who collaborates effectively across coding, clinical, and finance teams.
Adaptability to changing payer rules, software updates, and process improvements.
Strong organizational skills for managing multiple accounts and detailed documentation.
Analytical mindset to interpret AR metrics, identify trends, and recommend process changes.
High level of integrity and commitment to protecting patient data and maintaining confidentiality.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED; equivalent work experience in billing acceptable.

Preferred Education:

Associate degree in Health Information Management, Healthcare Administration, Accounting, or related field.
Certifications such as Certified Billing and Coding Specialist (CBCS), Certified Professional Coder (CPC), or Certified Healthcare Billing and Coding Specialist (CHB) are preferred.

Relevant Fields of Study:

Health Information Management
Medical Billing and Coding
Healthcare Administration
Business, Accounting, or Finance

Experience Requirements

Typical Experience Range:

1–5 years of medical billing, claims processing, or revenue cycle experience; entry-level roles may start at 0–1 year with strong training.

Preferred:

2+ years of experience in medical billing with demonstrated expertise in payer follow-up, denial management, and AR aging reduction; experience with specialty-specific billing (e.g., ambulatory, surgical, behavioral health) is advantageous.