Key Responsibilities and Required Skills for Medical Collections Specialist

🎯 Role Definition

A Medical Collections Specialist is responsible for managing outstanding patient accounts receivable (AR), investigating and resolving billing and insurance issues, communicating with patients and payers, and ensuring timely recovery of revenue while maintaining compliance with HIPAA and state collections regulations. This role requires strong knowledge of medical billing, claims processing, denial management, insurance verification, and excellent written and verbal patient communication.

📈 Career Progression

Typical Career Path

Entry Point From:

Patient Account Representative / Patient Financial Representative
Medical Biller / Medical Coding Specialist
Customer Service Representative with healthcare experience

Advancement To:

Senior Medical Collections Specialist
AR / Revenue Cycle Supervisor
Denials Management Lead
Patient Financial Services Manager
Revenue Cycle Manager

Lateral Moves:

Insurance Verification Specialist
Financial Counselor / Patient Advocate
Claims Examiner / Denials Specialist

Core Responsibilities

Primary Functions

Proactively manage assigned patient accounts receivable (AR) aging buckets — contact patients and guarantors by phone, email, and mail to negotiate payment plans, collect outstanding balances, and document all account activity in the billing system.
Investigate and resolve claim denials and rejections by obtaining necessary documentation, submitting corrected claims, and following payer-specific appeals processes to maximize reimbursement and reduce write-offs.
Perform insurance follow-up and timely claims resubmission, including verifying patient coverage, eligibility, pre-authorization requirements, and coordinating with providers to secure missing clinical information to support claims.
Review and analyze Explanation of Benefits (EOBs), remittance advices, and ERA/EFT transactions to identify underpayments, short pays, and systemic payment posting errors; initiate payer disputes and post adjustments as appropriate.
Conduct skip-tracing and account research using internal and external resources to locate guarantors, update contact information, and ensure accurate billing addresses to improve collection rates.
Establish and manage patient payment plans consistent with organizational policies; collect upfront payments, set recurring electronic payments, and monitor adherence while documenting financial agreements.
Apply HIPAA and state privacy laws to all patient communications and records, ensuring sensitive information is only shared with authorized parties and that all collections activities remain compliant.
Escalate complex accounts to the denials team or supervisor when clinical documentation, contractual issues, or payer policy disputes require advanced intervention.
Work closely with clinical, registration, coding, and billing teams to resolve root causes of recurring denials, inaccurate charges, or eligibility issues that negatively impact AR performance.
Maintain accurate and thorough documentation of collection activities, payer conversations, patient promises to pay, and appeal submissions in the electronic health record (EHR) or billing system to support auditability.
Reconcile daily cash receipts, apply payments to appropriate accounts, resolve posting discrepancies, and coordinate with cash posting teams to ensure accurate financial records.
Monitor and meet individual and team collection performance metrics (e.g., days in AR, net collection rate, promise-to-pay kept, and call productivity) and contribute to continuous improvement initiatives to enhance revenue cycle KPIs.
Contact insurance payers for claim status inquiries, negotiate reductions when appropriate, and obtain written confirmations of payer commitments to expedite resolution and prevent recurrence.
Provide professional, empathetic patient financial counseling; explain billing statements, insurance benefits, out-of-pocket responsibility, and available financial assistance programs to reduce barriers to payment.
Validate and update demographic and insurance information at first contact and during follow-up to prevent claims denials due to incorrect data, and to identify secondary or tertiary coverage.
Prepare and submit accounts for third-party collections or legal referral in accordance with organizational policies and regulatory requirements when internal collection efforts are exhausted.
Participate in quality assurance reviews and audits of collection activities to ensure compliance with internal controls, regulatory requirements, and best practice documentation standards.
Collaborate on periodic AR clean-up projects, focused on high-dollar aged accounts or accounts with complex payer issues, to accelerate revenue recovery and minimize bad debt.
Educate front-line staff on common billing and documentation issues driving denials or delayed payments and recommend process improvements to registration, coding, or charge capture workflows.
Use analytics and reporting tools to identify trends in denials, underpayments, and payer behaviors; provide actionable feedback and recommendations to leadership to reduce future revenue leakage.
Manage outbound collections campaigns, including statement cycles, automated messaging, and timed follow-up workflows, optimizing cadence to maximize patient engagement and payments.
Maintain knowledge of current payer policies, fee schedules, state collection laws, and federal healthcare regulations to ensure compliant and effective collections practices.

Secondary Functions

Assist with special projects such as system implementations, billing platform conversions, and process re-engineering initiatives related to revenue cycle optimization.
Train and mentor new collections staff on systems, policies, customer service standards, and effective collections techniques.
Generate and distribute regular AR reports, aged trial balances, and payer-specific performance dashboards to leadership and stakeholders.
Support periodic external audits and provide requested documentation for payer audits, governmental reviews, and internal compliance checks.
Participate in cross-functional meetings to align clinical and financial teams around process improvements that reduce denials and accelerate cash flow.
Recommend and help implement automation opportunities (e.g., payment self-service options, automated appeals routing) to improve efficiency and patient satisfaction.

Required Skills & Competencies

Hard Skills (Technical)

Medical billing and collections expertise, including accounts receivable (AR) management and revenue cycle fundamentals.
Strong knowledge of CPT, ICD-10, HCPCS coding basics and how coding impacts claims and payer adjudication.
Proficient with Electronic Health Record (EHR) and Practice Management systems (examples: Epic, Cerner, Athenahealth, Meditech, NextGen) and AR/billing platforms.
Experience with clearinghouses and payer portals (e.g., Availity, Change Healthcare) for claim submission, status checks, and remits.
Denials management and appeals workflow experience: identifying denial reasons, compiling supporting documentation, and tracking appeals outcomes.
Proficiency with ERAs/EFTs, EOB/RA reconciliation, payment posting, and adjustment entries.
Skilled in insurance verification, eligibility checks, coordination of benefits (COB), and secondary payer follow-up.
Familiarity with HIPAA privacy & security regulations, state collection laws, and Fair Debt Collection Practices Act (FDCPA) constraints where applicable.
Advanced Excel and data analysis skills: pivot tables, VLOOKUP/XLOOKUP, filters, and basic formula-based reconciliations for AR reporting.
Experience with skip-tracing tools, credit bureau utilities, and third-party collections software for escalated accounts.
Knowledge of patient financial assistance programs, Medicaid/Medicare billing rules, and charity care policies.

Soft Skills

Exceptional verbal and written communication with strong negotiation and persuasion abilities to secure payments while maintaining patient dignity.
High emotional intelligence and empathy when discussing financial matters with vulnerable patients and families.
Strong attention to detail and accuracy in documentation, payment posting, and claims research.
Problem-solving mindset with the ability to analyze payer feedback and identify sustainable process fixes.
Time management, organization, and the ability to prioritize a high-volume workload to meet performance targets.
Team player who collaborates effectively across clinical, billing, and provider teams to resolve complex account issues.
Professionalism, resilience, and the ability to handle challenging or adversarial conversations tactfully.
Continuous improvement orientation and openness to feedback, training, and new technology adoption.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED required; equivalent combination of education and collections/billing experience considered.

Preferred Education:

Associate degree or certificate in Healthcare Administration, Medical Billing & Coding, Business, or related field.
Professional certifications such as Certified Billing and Coding Specialist (CBCS), Certified Professional Biller (CPB), or Registered Revenue Cycle Representative (RRCR) are a plus.

Relevant Fields of Study:

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

Experience Requirements

Typical Experience Range:

1–5 years of medical collections, patient financial services, or revenue cycle experience; experience in a hospital, multi-specialty clinic, or physician group preferred.

Preferred:

2+ years specifically managing AR aging buckets, denials and appeals, payer follow-up, and patient payment arrangements.
Demonstrated success meeting collection targets, reducing days in AR, and improving net collection rates.
Familiarity with Medicare/Medicaid billing rules and commercial payer contract nuances desirable.