Key Responsibilities and Required Skills for Medical Billing and Collections Specialist

🎯 Role Definition

A Medical Billing and Collections Specialist is responsible for end-to-end revenue cycle and accounts receivable (AR) management for ambulatory, clinic, or hospital services. This role combines technical knowledge of coding (CPT, ICD-10, HCPCS), insurance claims processing, electronic claim submission, denial management and patient account collections to maximize clean claims, reduce days in AR, and ensure compliant, timely reimbursement. The specialist serves as the primary liaison between the practice, payers, patients, and internal clinical teams to expedite payments and resolve billing discrepancies.

Key SEO terms: medical billing, medical collections, revenue cycle management, claims processing, denial management, patient billing, insurance follow-up, accounts receivable.

📈 Career Progression

Typical Career Path

Entry Point From:

Medical Billing Clerk / Billing Assistant
Patient Financial Representative / Patient Access Representative
Medical Records Technician / Medical Coder (entry-level)

Advancement To:

Senior Billing & Collections Specialist
Revenue Cycle Supervisor / Manager
Billing Operations Manager
Practice Administrator or Finance Lead

Lateral Moves:

Insurance Verification Specialist
Patient Financial Counselor / Patient Advocate
Medical Coding Specialist (CPC/CCS)

Core Responsibilities

Primary Functions

Manage the full billing cycle for assigned provider panels or service lines, including charge entry, coding verification (CPT, ICD-10, HCPCS), claim creation, and electronic submission to clearinghouses and payers to ensure timely revenue capture.
Perform daily payment posting and reconciliation of insurance and patient payments, reconciling EOBs/EORs, applying contractual adjustments, and preparing accurate deposit batches to maintain clean ledgers.
Conduct proactive accounts receivable follow-up by researching unpaid claims, tracking outstanding balances, and initiating timely appeals and corrective claim resubmissions to reduce days in AR and improve cash flow.
Analyze denials and partial-payments to identify root causes, prepare detailed appeal documentation, and work with payers and clinical staff to obtain overturned denials and correct claim adjudication.
Verify patient insurance eligibility and coverage benefits prior to or at time of service, obtain authorizations and referrals when required, and document verification outcomes in the EHR or billing system.
Maintain and update payer-specific billing rules, fee schedules, and payer contract terms to ensure accurate claim submission and appropriate reimbursement.
Communicate with patients about billing questions, outstanding balances, payment options, and payment plans; counsel patients on financial responsibility and set up installment plans when applicable.
Prepare and send patient statements, collection letters, and coordinate outbound collection calls; escalate delinquent accounts to third-party collections in accordance with company policy and regulatory requirements.
Perform detailed account research using EHRs, clearinghouse reports, payer portals, and phone communications to resolve complex claim and payment discrepancies.
Collaborate directly with clinical providers and office staff to clarify documentation, secure missing information, and correct coding errors that affect claim acceptance and reimbursement.
Maintain compliance with HIPAA, state regulations, and payer guidelines when handling confidential patient and payment information to safeguard the organization against regulatory risk.
Generate, analyze, and present weekly/monthly revenue, aging AR, denial trend, and productivity reports to leadership, recommending process improvements or training to drive collections performance.
Work with IT and vendors to test and implement billing system updates, EDI mapping changes, clearinghouse integrations, and EHR interfaces to ensure accurate data flow and minimize claim rejections.
Train and mentor new billing and collections staff on procedural workflows, payer requirements, and best practices for documentation, coding, and communications with payers and patients.
Manage refunds, credit balances, and adjustments by researching root cause and issuing refunds or writes-offs per policy while maintaining detailed audit trails.
Maintain accurate and organized account documentation and audit logs for internal audits, external reviews, and payer audits to substantiate billing activities and reimbursements.
Coordinate preauthorization/authorization follow-up with insurance companies and clinical coordinators to confirm medical necessity and avoid denials based on missing authorizations.
Negotiate payment arrangements or settlements with patients and third-party payers when applicable, balancing revenue recovery with patient satisfaction and regulatory compliance.
Implement and follow up on denial-prevention initiatives, including chart audits, coding audits, and provider education sessions to reduce recurring claim denials and improve reimbursement rates.
Reconcile vendor and payer remittance reports and resolve discrepancies between ledger balances and bank deposits to ensure accurate financial reporting.
Execute special projects to optimize revenue cycle KPIs (e.g., net collections, denial rate, AR days), including process mapping, workflow redesign, or piloting new collection strategies.

Secondary Functions

Assist with periodic audits and quality assurance reviews of billing processes, documentation, and coding accuracy to support compliance and process improvement.
Support cross-functional initiatives with patient access, clinical operations, and finance to streamline front-end and back-end revenue cycle processes.
Participate in vendor and payer meetings to resolve outstanding systemic issues and implement corrective actions.
Maintain ongoing education on coding updates, payer policy changes, and regulatory shifts that affect billing and collections practices.
Create and maintain standard operating procedures (SOPs), job aids, and training materials for billing and collections activities.
Contribute to forecasting exercises and budget planning by providing historical AR trends, denial analytics, and revenue leakage estimates.
Serve as a point of contact for internal inquiries related to billing escalations, external audits, and payer dispute resolution.
Recommend and help test automation opportunities (e.g., auto-reprocessing rules, denial routing logic) to increase efficiency and reduce manual workload.

Required Skills & Competencies

Hard Skills (Technical)

CPT, ICD-10-CM and HCPCS coding knowledge with the ability to validate coding accuracy and identify miscoding that impacts reimbursement.
End-to-end claims processing experience (electronic and paper), including claims creation, clearinghouse submission, ERA/EOB reconciliation, and appeals.
Denial management and appeals: building appeal packages, submitting corrected claims, and negotiating denials with payers.
Strong accounts receivable (AR) management and aged AR reduction techniques.
Familiarity with major EHR/billing systems such as Epic, Cerner, Athenahealth, Kareo, NextGen, or eClinicalWorks and experience with clearinghouses (Availity, Change Healthcare).
Payment posting, bank reconciliation, and adjustment accounting to reconcile revenue and prepare accurate deposits.
Payer portal navigation and payer-specific rules management (Medicare, Medicaid, commercial payers).
Electronic Data Interchange (EDI), ERA/835 and 837 file formats, and experience working with clearinghouse reports.
Proficiency with Microsoft Excel (pivot tables, VLOOKUP, filters) and reporting tools for AR analysis and KPI tracking.
Knowledge of HIPAA privacy/security requirements and healthcare regulatory compliance related to billing and collections.
Experience managing patient payment plans, refund processing, and collection agency workflows.
Experience with revenue cycle KPIs and financial reporting (denial rate, AR days, net collection rate).

Soft Skills

Excellent verbal and written communication skills for interacting with patients, payers, and clinicians in a professional, empathetic manner.
Strong analytical and problem-solving abilities to identify root causes for denials and AR trends and propose corrective actions.
High attention to detail and accuracy in coding, payment posting, and documentation to reduce rework and audit exposure.
Time management and organizational skills to prioritize high-value claims and manage a high-volume workload.
Customer service orientation with the ability to de-escalate billing disputes and maintain a patient-centered approach.
Teamwork and collaboration skills to work cross-functionally with clinical, front-desk, and finance teams.
Adaptability and continuous learning mindset to keep pace with changing payer policies and coding updates.
Initiative and self-direction to lead process improvement projects and maintain momentum on aged accounts.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED with completion of a medical billing and coding certificate program or equivalent on-the-job training.

Preferred Education:

Associate degree in Health Information Management, Allied Health, Business Administration, or a related field.
Professional certification such as Certified Professional Biller (CPB), Certified Professional Coder (CPC), or Registered Health Information Technician (RHIT) is highly desirable.

Relevant Fields of Study:

Health Information Management / Medical Billing & Coding
Healthcare Administration / Business Administration
Finance or Accounting (for stronger AR and reconciliation skills)

Experience Requirements

Typical Experience Range:

2 to 5 years of direct medical billing and collections experience in physician practices, outpatient clinics, or hospital revenue cycle.

Preferred:

3+ years of progressive experience handling AR follow-up, denial appeals, and payer negotiations.
Prior experience with specific EHR/billing systems (Epic, Athenahealth, Cerner) and clearinghouse/EDI operations.
Demonstrated success reducing aged AR, improving denial rates, and contributing to revenue cycle process improvements.

If you would like, I can also tailor this job description for specific settings (e.g., ambulatory clinic vs. hospital outpatient) or optimize it for job board postings (LinkedIn, Indeed, Glassdoor).