Healthcare Claims Processing Representative

Job Summary :

The Accounts Receivable Specialist is responsible for managing the financial reimbursement process, including insurance claim follow-up, payment posting, and resolving outstanding patient and insurance balances. This role plays a key part in maintaining healthy cash flow and ensuring accuracy in revenue collection.

Key Responsibilities :

🔹 Insurance & Claims Management

Follow up on outstanding insurance claims and unpaid balances.

Investigate and resolve claim denials or rejections.

Resubmit corrected claims and coordinate with the billing team as needed.

🔹 Pre-Authorization / Referral Coordinator

Verifies coverage and ensures services meet payer requirements for prior authorization.

Often works closely with eligibility verification.

Requests and obtain necessary authorization for services.

🔹 Patient Account Handling

Review and manage aging reports for patient balances.

Contact patients to resolve outstanding debts and offer payment options.

Respond to patient billing inquiries courteously and accurately.

🔹 Payment Posting & Reconciliation

Accurately post payments from insurance companies and patients.

Reconcile explanation of benefits (EOBs) and electronic remittance advice (ERAs).

Identify and escalate payment discrepancies.

🔹 Reporting & Compliance

Maintain documentation in accordance with HIPAA and organizational standards.

Monitor trends in claim denials and unpaid balances.

Submit regular reports to supervisors or finance teams.

🔹 Collaboration & Communication

Work closely with billers and front-office staff to resolve discrepancies.

Provide feedback for process improvement within the AR function.

Qualifications :

High school diploma or equivalent (required)

2+ years of experience in medical billing, healthcare AR, or revenue cycle roles.

Familiarity with EHR systems (e.g., Epic, Athena, Cerner) and clearinghouses.

Strong understanding of insurance processes, EOBs, and HIPAA compliance.

Excellent communication and organizational skills.

Preferred Skills :

• Knowledge of Medicaid and commercial insurance guidelines.
• Experience in high-volume claim processing environments.
• Ability to analyze data and solve problems independently.
• Ability to communicate professionally with coworkers, patients and outside agencies.