Key Responsibilities and Required Skills for Billing Representative

🎯 Role Definition

A Billing Representative is the primary point of contact for invoice generation, claims submission, payment posting, accounts receivable management, and payer/patient communications. The role requires strong knowledge of billing systems, claim adjudication, denial management, and relevant coding/insurance guidelines. Billing Representatives ensure timely collection, accurate account reconciliation, and compliance with internal controls and regulatory requirements, supporting the organization's revenue cycle and cash flow objectives.

📈 Career Progression

Typical Career Path

Entry Point From:

Billing Clerk or Accounts Receivable Clerk
Medical Receptionist or Front Desk Coordinator (healthcare)
Customer Service Representative with billing or collections exposure

Advancement To:

Senior Billing Representative / Lead Billing Specialist
Billing Supervisor or Accounts Receivable Supervisor
Revenue Cycle Manager or AR Manager

Lateral Moves:

Insurance Verification Specialist
Patient Financial Counselor / Cash Posting Specialist

Core Responsibilities

Primary Functions

Prepare, generate, and submit accurate invoices and claims to commercial insurers, Medicare, Medicaid, and patients using electronic and paper processes, ensuring timely submission in accordance with payer-specific rules.
Review patient account information, verify insurance coverage, benefits, authorizations, and demographic data to minimize claim rejections and ensure correct billing.
Analyze Explanation of Benefits (EOBs) and remittance advice, post payments and adjustments to the general ledger or practice management system, and reconcile discrepancies between payments and billed charges.
Manage accounts receivable (AR) follow-up activities, monitor AR aging buckets, prioritize accounts for follow-up, and take ownership of high-dollar and aged receivables until resolution.
Identify and research claim denials and rejections, determine root causes (coding, eligibility, eligibility, bundling, authorization, documentation), and submit corrected claims, appeals, or refunds as required.
Prepare and submit claim appeals and supporting documentation to payers, track appeal timelines, and escalate unresolved denials to payer relations or clinical documentation teams when necessary.
Communicate professionally with insurance payers, clearinghouses, third-party administrators, and patients to obtain claim status updates, payment explanations, and outstanding information.
Maintain accurate patient account records, document all communications, actions, and next steps in the billing system to ensure a clear audit trail and consistent follow-up.
Perform payment posting for electronic and manual payments, reconcile cash receipts, handle patient refunds, and coordinate with the finance department for deposit and reconciliation procedures.
Conduct billing corrections, write-offs, and adjustments in accordance with company policy and approval matrices, ensuring proper authorization and documentation for all adjustments.
Use billing and EHR/PM systems (e.g., Epic, Cerner, Athenahealth, Kareo, NextGen, Meditech) to process claims, print statements, and run billing reports; recommend process improvements to increase efficiency and reduce errors.
Evaluate contractual payer agreements and perform payer contract verification to ensure claims are billed at the correct contractual rates and co-payments/co-insurance are applied appropriately.
Manage patient billing inquiries, provide clear explanations of charges, insurance responsibilities, and payment options, and set up payment arrangements when applicable to minimize bad debt.
Collaborate with clinical staff, coding specialists, and case management to clarify documentation or obtain necessary clinical notes to support claims and appeals.
Monitor refunds and overpayments; research and coordinate repayment or refund processes in compliance with payer guidelines and internal policies.
Participate in periodic audits of billing files, claims, and revenue cycle workflows to ensure compliance with HIPAA, billing regulations, and internal controls; address audit findings with corrective actions.
Produce and analyze routine and ad-hoc billing reports (daily billing, AR aging, denial trends, collection rates) to inform management decisions and identify areas for revenue recovery.
Train and mentor junior billing staff on system navigation, claim submission standards, denial handling, and customer service best practices to maintain team performance consistency.
Maintain up-to-date knowledge of payer policy changes, industry trends, coding updates (ICD-10, CPT, HCPCS), and regulatory requirements affecting billing and reimbursement.
Coordinate with collections agencies for delinquent accounts following internal escalation rules and ensure proper documentation and authorization for account transfers.
Reconcile monthly billing and AR activity with the general ledger and accounting team, support month-end and year-end close activities, and provide documentation for external audits.
Facilitate process improvement projects to streamline billing workflows, reduce claim denial rates, and enhance patient payment experiences through automation and policy updates.
Ensure strict confidentiality of patient and financial information, comply with HIPAA, and follow company policies regarding data protection and information security.
Act as point person for system upgrades, billing system testing, and validation of payer interfaces to ensure seamless claim flow during technical changes.

Secondary Functions

Assist with special billing projects such as mass adjustments, system conversions, or policy rollouts and provide subject matter expertise on billing implications.
Support internal and external audit requests by compiling documentation, verifying account histories, and responding to auditor inquiries in a timely manner.
Collaborate with revenue integrity and compliance teams to investigate potential billing irregularities and implement corrective actions to maintain regulatory compliance.
Create and maintain standard operating procedures (SOPs), knowledge base articles, and training materials for common billing scenarios and payer-specific requirements.
Participate in cross-functional teams with finance, clinical, and IT stakeholders to test and validate workflow changes that impact billing and collections.
Provide feedback to leadership on trends in denials, payer behavior, and patient payment barriers to influence policy and pricing strategies.
Serve as backup for related finance functions during peak periods or staff absences, including basic AR reporting and statement generation.
Engage in continuous professional development, attend training on new payer portals, coding updates, and billing best practices to maintain technical proficiency.

Required Skills & Competencies

Hard Skills (Technical)

Medical billing and claims submission expertise for commercial, Medicare, and Medicaid payers.
Knowledge of ICD-10, CPT, and HCPCS coding basics and how coding impacts claim adjudication and reimbursement.
Proficiency with electronic claims clearinghouses, EDI formats (837/835), and payer portals.
Experience with practice management and EHR/billing systems (examples: Epic, Cerner, Athenahealth, Kareo, NextGen, Medisoft).
Strong accounts receivable management skills, AR aging analysis, and cash application techniques.
Denial management and appeal preparation, including root-cause analysis and trending.
Payment posting, reconciliation, and adjustment/write-off procedures with an understanding of general ledger implications.
Proficiency in Microsoft Excel (VLOOKUP, pivot tables, data filtering) and experience generating billing/AR reports.
Familiarity with billing compliance, HIPAA regulations, and payer-specific contractual requirements.
Experience with collections processes and working with external collection agencies.
Ability to use CRM or ticketing systems to track billing cases and communications.
Knowledge of revenue cycle KPIs (Days Sales Outstanding, denial rate, net collection rate) and performance monitoring.

Soft Skills

Clear, empathetic verbal and written communication for interacting with payers and patients.
Strong analytical and problem-solving mindset to research and resolve complex billing issues.
High attention to detail and accuracy when reviewing claims, EOBs, and financial records.
Excellent organizational skills and ability to prioritize high-volume workloads under deadlines.
Customer-service orientation with tactful conflict resolution and negotiation skills.
Team collaboration and ability to work cross-functionally with clinical and finance partners.
Adaptability to evolving payer rules, software changes, and process updates.
Time management and self-motivation to close outstanding AR and meet productivity targets.
Confidentiality and ethical judgment when handling sensitive patient and financial data.
Initiative to identify process improvements and follow through on implementation.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED; equivalent experience in billing or accounts receivable is acceptable.

Preferred Education:

Associate degree in Accounting, Health Information Management, Business Administration, or related field.
Certificate in Medical Billing and Coding or Revenue Cycle Management is a plus.

Relevant Fields of Study:

Health Information Management
Accounting / Finance
Business Administration
Medical Billing & Coding

Experience Requirements

Typical Experience Range:

1–3 years for Billing Representative / Entry-level roles
3–5 years for mid-level Billing Representative with more complex payer experience

Preferred:

2–4 years of medical billing or AR experience for healthcare positions; 3+ years for specialty or high-volume environments.
Prior experience with specific billing systems used by the employer (list preferred systems in job posting).
Demonstrated history of reducing denial rates, improving AR performance, or recovering revenue through appeals.