Job Description

• Claim Follow-Up: Monitor aging out-of-network claims, contacting insurance payers to ensure timely processing and receipt of payment.
• Reimbursement Negotiation: Interface with Third-Party Administrators (TPAs) and insurance companies to negotiate maximum allowable rates for specialized out-of-network procedures.
• Appeals & Denials: Research reasons for underpayments or claim denials, gather necessary clinical documentation, and submit formal written appeals.
• Patient Billing & Communication: Clearly explain financial responsibility to patients, manage patient coinsurance/deductibles, and establish payment plans or settlements.
• Account Reconciliation: Ensure payments, adjustments, and refunds are posted accurately while maintaining meticulous records of all collection and appeal activities.

• Experience: 2 to 5 years in medical billing, coding, and third-party insurance collections, with specific exposure to out-of-network claims.
• Payer Knowledge: Deep understanding of commercial insurance policies, managed care contracts, and out-of-network benefit structures.
• Technical Proficiency: Familiarity with interpreting medical codes (ICD-10, CPT, HCPCS) and navigating Electronic Health Record (EHR) and medical claims clearinghouse software.
• Soft Skills: Exceptional negotiation, verbal communication, and conflict-resolution skills to deal with resistant payers and concerned patients.

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