Key Responsibilities and Required Skills for Medical Billing Representative

🎯 Role Definition

The Medical Billing Representative is responsible for full-cycle medical claims processing and revenue recovery across healthcare payers, including insurance verification, claim creation and submission, denial management, appeals, patient statements, and accounts receivable follow-up. This role ensures accurate CPT/HCPCS and ICD-10 coding alignment with documentation, compliance with HIPAA and payer policy, and timely resolution of payer and patient inquiries to optimize cash collections and minimize days in A/R.

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📈 Career Progression

Typical Career Path

Entry Point From:

Medical Receptionist or Front Desk Representative with exposure to insurance verification and patient intake.
Medical Records Clerk or Health Information Technician with familiarity of ICD-10/CPT.
Customer Service Representative in a healthcare or insurance environment.

Advancement To:

Senior Medical Biller / Revenue Cycle Specialist
Accounts Receivable (A/R) Supervisor or Billing Team Lead
Revenue Integrity Analyst or Denials Manager
Health Information Manager or Practice Manager (with additional education/certification)

Lateral Moves:

Medical Coder (CPC/CCA)
Patient Financial Advocate / Patient Accounts Specialist
Insurance Verification Specialist

Core Responsibilities

Primary Functions

Prepare, review and submit clean claims to commercial insurers, Medicare, and Medicaid using industry-standard clearinghouses or integrated EHR/EMR billing modules, ensuring claims meet payer-specific formatting and compliance requirements.
Analyze insurer Explanation of Benefits (EOBs) and remittance advices to post payments accurately, identify discrepancies, and reconcile payments against billed charges to maintain accurate patient and provider accounts.
Perform proactive denial management: investigate denied or rejected claims, identify root causes (coding, missing documentation, eligibility, bundling), prepare and submit corrected claims or appeals, and track results to closure.
Verify patient insurance eligibility and benefits prior to services and at point of scheduling; document coverage details, pre-authorization requirements, and patient financial responsibility for effective point-of-service collections.
Maintain accounts receivable aging reports and prioritize follow-up on aged denials and unpaid balances to reduce days in A/R and optimize cash flow for the practice or facility.
Initiate and manage payer appeals and grievances, preparing supporting documentation, medical necessity justification, and corresponding with payers to recover denied or underpaid claims.
Coordinate with clinical staff and physicians to obtain missing documentation, clarify diagnosis or procedure notes, and ensure coding accuracy to support claims and appeals.
Apply CPT, HCPCS and ICD-10 coding conventions appropriately when preparing claims or when reviewing coded encounters, identifying potential miscoding issues and escalating to coding specialists when necessary.
Post patient payments, adjust account balances, set up payment plans, and generate patient statements while explaining charges and insurance responsibilities in a professional manner.
Research and resolve patient and payer inquiries via phone, email, or secure messaging, providing clear explanations of benefits, balances, and next steps while maintaining HIPAA confidentiality.
Collaborate with the revenue cycle team to implement process improvements for billing workflows, denial reduction strategies, and payer communication protocols to increase first-pass claim acceptance rates.
Use billing software (e.g., Cerner, Epic, Athenahealth, NextGen, eClinicalWorks, Quest/Sunrise) and clearinghouse tools to submit, track, and resubmit claims, maintaining accurate logs and documentation for audit trails.
Manage coordination with third-party vendors, collection agencies, and financial counselors to address unresolved balances and escalate accounts as per organizational policies.
Monitor changes in payer policies, CMS guidelines, and regulatory updates (including Medicare/Medicaid fee schedules) and update billing practices to ensure ongoing compliance and reimbursement accuracy.
Reconcile monthly billing reports, provider fee schedules and contractual adjustments, ensuring charge capture completeness and contract compliance with payer agreements.
Conduct front-end patient financial counseling including benefit explanation, co-pay collection, and scheduling pre-authorizations to reduce financial surprises and bad debt.
Train and cross-train new billing staff on claim submission processes, denial workflows, and system navigation to ensure consistent operational performance across the billing team.
Produce routine and ad-hoc financial and operational reports related to claims submission rates, denial trends, A/R aging, and payer performance to support management decision-making.
Participate in internal and external audits by preparing supporting documentation, responding to audit inquiries, and implementing corrective actions to address findings.
Ensure adherence to HIPAA, fraud, waste and abuse policies by safeguarding patient data, validating billing integrity and reporting suspicious activity according to organizational protocols.
Maintain detailed documentation of account actions, payer communications, and appeal outcomes in the patient’s account record to provide a clear history for future reference.

Secondary Functions

Assist in coding quality reviews and collaborate with certified coders to clarify documentation and coding queries that affect billing and reimbursement.
Support revenue cycle projects such as EHR upgrades, clearinghouse integrations, and automation initiatives by testing claim submission scenarios and validating outputs.
Provide subject matter expertise for payer contract negotiations by offering insights on denial trends, reimbursement issues, and charge capture opportunities.
Help develop patient-facing educational materials and FAQs about billing, insurance, and payment options to improve patient satisfaction and self-service.
Participate in cross-functional meetings with clinical operations, compliance, and IT to address systemic billing barriers and streamline end-to-end revenue processes.
Escalate complex or high-dollar appeals to management and coordinate multi-department responses for timely resolution.
Perform periodic self-audits and contribute to team ledger reconciliations to ensure accurate financial reporting and reduce write-offs.
Maintain a knowledge base of payer phone numbers, claim submission portals, and escalation contacts to expedite payer communications.
Collect and analyze metrics on first-pass acceptance rates, denial reasons, and AR days to prioritize improvement efforts and report on KPIs.
Provide back-up support for front desk or scheduling functions during peak periods or staff shortages to maintain continuity of patient services.

Required Skills & Competencies

Hard Skills (Technical)

Proficiency with medical billing software and practice management systems (examples: Epic/Cadence, Athena, NextGen, Cerner, eClinicalWorks, Kareo).
Hands-on experience with clearinghouse submission tools (Change Healthcare, Availity, Trizetto) and electronic/multi-payer claim formats (ANSI X12 837/835).
Strong working knowledge of CPT, HCPCS, and ICD-10 code sets and the ability to identify coding issues that impact reimbursement.
Demonstrated experience interpreting EOBs, remittance advices, and ERA/835 files for payment posting and reconciliation.
Familiarity with payer policies for Medicare, Medicaid, commercial, and Medicare Advantage plans, including pre-authorization and medical necessity criteria.
Denials management and appeals workflow expertise, including drafting appeal letters and submitting medical documentation packages.
AR management competencies: aging analysis, follow-up strategies, payment posting, adjustments, and collections best practices.
Experience with patient billing, statement generation, payment plan set up, and point-of-service collections.
Understanding of HIPAA regulations, PHI handling, and privacy/security best practices for patient data.
Basic Excel and reporting skills for tracking denial trends, A/R aging detail, and performance metrics; familiarity with pivot tables preferred.

Soft Skills

Excellent verbal and written communication skills for interacting with patients, providers, and payer representatives professionally and persuasively.
Strong attention to detail and accuracy in claim preparation, documentation, and payment posting.
Problem-solving mindset and persistence when researching complex denials and payment discrepancies.
Time management and prioritization skills to handle high-volume workflows and meet billing deadlines.
Customer-service orientation with empathy when discussing financial responsibility and resolving patient concerns.
Team collaboration skills to work effectively with clinical, coding, and accounts teams across the revenue cycle.
Initiative and adaptability to stay current with frequent payer policy changes and system updates.
Confidentiality and ethical judgment in handling sensitive patient and financial information.
Coaching and mentoring ability to assist junior billing staff and promote consistent team performance.
Analytical mindset to review KPIs and implement process improvements that impact cash collections.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED; relevant vocational certificate in medical billing/medical coding preferred.

Preferred Education:

Associate degree in Health Information Management, Health Administration, Business Administration, or related field.
Relevant certifications such as Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS), or Certified Billing & Coding Specialist (CBCS) are advantageous.

Relevant Fields of Study:

Health Information Management
Medical Billing & Coding
Healthcare Administration
Business or Accounting

Experience Requirements

Typical Experience Range:

1 to 5 years of medical billing experience in a physician practice, outpatient clinic, hospital billing office, or third-party billing service.

Preferred:

2+ years of demonstrated success in claims submission, denials resolution, AR follow-up, and payer communications; experience with both commercial and government payers (Medicare/Medicaid); experience with EHR-integrated billing systems and clearinghouses.