PHYSICIAN PRACTICE BILLING SPECIALIST

JOB SUMMARY

Under the direction of the Director of Business Services and the Business Services Manager, the Physician Practice Billing Specialist performs physician practice billing functions to support timely and accurate reimbursement for services rendered. This position processes claims, resolves billing edits and denials, posts payments, reviews explanations of benefits (EOBs), and follows up on outstanding accounts. Follow-up activities may include appeals, patient responsibility statements, collection efforts, and communication with providers regarding missing information or coding-related concerns. The Physician Practice Billing Specialist provides professional and responsive customer service to patients, providers, insurance carriers, and internal departments while supporting effective communication throughout the billing process. This role ensures compliance with federal and state regulations, payer requirements, medical coding standards, HIPAA guidelines, and organizational policies and procedures. The incumbent must demonstrate strong attention to detail, sound problem-solving skills, and the ability to work independently in a fast-paced healthcare environment.

STANDARDS OF PERFORMANCE

Claims Review, Submission, and Follow-Up

• Review patient accounts for completeness and accuracy before claim submission, including demographic, insurance, coding, and billing information.
• Prepare, review, and submit clean electronic and paper claims to commercial insurers, government payers, and other third-party payers.
• Monitor claim submissions, payer edits, rejections, denials, delayed payments, and underpayments to support timely reimbursement.
• Investigate, correct, appeal, and resubmit rejected or denied claims with appropriate supporting documentation.
• Review explanations of benefits and remittance advice to verify reimbursement accuracy and identify payment discrepancies.

Accounts Receivable, Collections, and Payment Resolution

• Monitor accounts receivable aging reports and work assigned unpaid, denied, underpaid, delayed, and delinquent accounts to reduce outstanding balances and accounts receivable days.
• Research and resolve billing discrepancies, payer disputes, patient billing concerns, claim denials, and account variances in a timely manner.
• Complete appropriate collection activities, including patient follow-up, account documentation, and referral recommendations for delinquent accounts based on established criteria.
• Coordinate with physician offices, insurance companies, internal departments, and external agencies to resolve billing issues and expedite payment.

Payment Posting, Statements, and Account Reconciliation

• Post insurance and patient payments accurately, including contractual adjustments, allowances, refunds, and credit balances, in accordance with policy.
• Prepare, review, and send patient statements accurately and on time in accordance with organizational procedures.
• Evaluate patient financial circumstances and establish approved payment arrangements consistent with organizational guidelines.
• Reconcile payment transactions and identify account discrepancies for timely correction.

Patient, Payer, and Internal Customer Service

• Respond to patient and payer inquiries in a professional, courteous, and accurate manner.
• Explain charges, insurance payments, balances, payment options, and patient financial responsibilities clearly and respectfully.
• Resolve patient billing concerns and account discrepancies promptly while maintaining exceptional customer service.
• Communicate effectively with patients, providers, clinic staff, insurance representatives, coworkers, and external agencies to support account resolution.

Compliance, Confidentiality, and Quality Assurance

• Maintain current knowledge of payer requirements, billing regulations, reimbursement guidelines, HIPAA privacy requirements, CMS standards, Joint Commission expectations, and applicable organizational policies.
• Protect the confidentiality of patient, financial, and organizational information at all times.
• Participate in audits, quality reviews, process improvement activities, and compliance reviews to support accuracy, efficiency, and regulatory readiness.

Reporting, Documentation, and Performance Improvement

• Document all account activity accurately, completely, and in accordance with billing system and organizational standards.
• Identify trends in denials, payment delays, payer issues, billing errors, and delinquent account activity, and report findings to leadership as appropriate.
• Assist with reports related to billing performance, collections, denials, accounts receivable trends, and revenue cycle improvement initiatives.

Education, Meetings, and Other Duties

• Participate in required education, continuing education activities, and scheduled departmental meetings as assigned.
• Perform other duties, special projects, and related responsibilities as assigned to support physician practice operations and revenue cycle objectives.

Requirements

Minimum Education Requirement: High school diploma or equivalent required.

Formal Training: Requires working knowledge of commercial insurance and government payer processes, along with effective written and verbal communication skills. Must demonstrate professionalism when interacting with the public, respond constructively to feedback, and manage challenging customer interactions in a manner that supports positive outcomes.

Licensure, Certification, and Registration: No licensure or registration is required for this position. Certification as a Certified Patient Accounts Representative (CPAR) and/or billing certification is preferred.

Work Experience: At least two years of billing experience in a family physician practice, hospital, or comparable healthcare revenue-cycle setting is strongly preferred.

Computer Skills: Intermediate proficiency in Microsoft Office Suite is required, including word processing and spreadsheet applications.