Medical Collections Representative

TPIRC and FAI•Long Beach, CA

2d•Onsite

About The Position

We are currently seeking a Medical Collections Representative who will play a critical role in ensuring the financial health of the organization by managing patient accounts, verifying eligibility and benefits, and overseeing collections activities. This position focuses on maximizing revenue through accurate account management, proactive follow-up, and effective communication with patients, payors, and internal teams. Additionally, the role emphasizes maintaining compliance with healthcare regulations, delivering exceptional customer service, and supporting efficient billing workflows to enhance operational efficiency and patient satisfaction.

Requirements

High School diploma or GED required
Customer Service experience required
3+ years of experience in medical billing required
3+ years of experience in inpatient/outpatient collections with a specialty group practice, with strong emphasis on appeals/underpayment collection activities.
Experience with out-of-network payors.
Comfortable navigating across various computer systems to locate critical information.
Knowledge of insurance policies/guidelines, EOB (Explanation of Benefits), prior authorization/referral processes, medical terminology, CPT/ICD/HCPCS coding preferred.
Experience with payor portals and affiliates.
Experience with EMR and PM systems (Athena, AdvancedMD a plus)
Experience using Salesforce a plus
Must have strong analytical skills, proficient with spreadsheets
Knowledge of health networks, IPA, HMO, PPO and contract affiliations
Proficiency in meeting deadlines and prioritize workload.
Ability to work independently, with direction, and as part of a team.
Exceptional organizational, presentation, and communication skills, both verbal and written
Experience with Microsoft Office Suite
Self-motivated, team-oriented, very responsible, and focused on exceeding customer expectations.

Nice To Haves

Medical billing and coding certification preferred.
Experience with Salesforce a plus

Responsibilities

Perform eligibility and benefits inquiries for both new and established patients, as needed.
Enter and make the appropriate changes in the EMR/PM system(s) and Salesforce regarding guarantor, payor, insurance eligibility and benefits coverage.
Determine and update copayment, coinsurance, deductible, and out-of-pocket amounts.
Verify eligibility and benefits using a real-time system response, through health plan portals, and/or via telephone to the health plan and/or guarantor.
Responsible for verifying COB information and communicating with the health plan and/or guarantor.
Manage a portfolio of assigned accounts that are aged in a timely manner.
Maximize revenue by providing appropriate follow-up and document actions taken.
Ability to read and interpret an explanation of benefits.
Knowledge of a CMS-1500 claim form and field requirements.
Effective appeal writing skills to submit claim appeals with supporting documentation per payor policy/guidelines.
Monitor and maintain revenue integrity through appropriate account adjustments, small balance write-off and payment reconciliations.
Reconcile customer disputes as they pertain to payment of outstanding balances.
Respond to correspondence timely.
Heavy telephone contact to ensure timely follow-up and account resolution, and customer service phone coverage.
Daily productivity standards and quality standards must be met.
Manage credit balances and refunds.
Document instructions for the RCM team in the EMR/PM system(s) and Salesforce.
Respond to and resolve patient statement and claim tickets via Salesforce.
Respond to emails and phone calls related to patient statements and claims.
Performs job duties with oversight.
Other duties as assigned.
Collaborate with patients or customers, third party institutions and other team members to research and resolve billing inconsistencies and errors.
Collect and maintain patient demographic and medical information required for medical billing.
Ensure patient documentation is scanned and filed correctly within the Electronic Medical Record (EMR).
Provide exceptional customer service.
Maintain and understand various medical billing software platforms.
Navigate insurance websites and answers customer inquiries.
Understand office visit fees including procedure and diagnosis codes.
Maintain confidentiality and adhere to HIPAA regulations.
Complete assigned tickets as required.
Adhere to policies and procedures, update of forms and manuals.
Assist in development and communication of SOP for key areas to improve accuracy and understanding of processes.
Support daily, weekly, and monthly medical billing metrics.
Identify issues and present possible solutions and/or suggestions to management.
Interfaces with other departments to resolve medical billing workflows.
Assist other staff and support the team approach.
Communicate appropriately and clearly to management, co-workers, and physicians.
Maintain all reference material that is provided by the supervisor, manager, or director.
Know and follow the Employee Handbook policies and procedures.
Maintain patient confidentiality so that HIPAA compliance is always observed.
Demonstrate honesty and integrity in everyday activities.
Arrive to work on time.
Consistently be at work.
Willingness to work overtime when requested.
Other duties as assigned.