Job Description

Job Description

Job Description

Job Title: Medical Billing Collections Representative (Commercial, Out-of-Network NJ & Spine/Orthopedic Experience)Position Summary:The Medical Billing Collections Representative is responsible for the collections process for medical claims, with a specialized focus on commercial insurance carriers, out-of-network (OON) claims, and spine/orthopedic procedures. The ideal candidate will have expertise in navigating complex insurance policies, understanding orthopedic/spinal procedures, ensuring timely payment, and resolving discrepancies between healthcare providers and insurance companies.Key Responsibilities:Collections and Follow-up:- Proactively monitor and follow up on unpaid or underpaid claims, particularly those from commercial insurance carriers and out-of-network payers, focusing on orthopedic and spine-related claims.- Communicate effectively with insurance companies, providers, and patients to ensure timely resolution of outstanding balances, including those for high-cost spine and orthopedic treatments.- Manage claim denials, including those specific to spine and orthopedic services, by working with insurance carriers to resolve issues and submit timely appeals.- Collaborate with Management and the coding team to ensure correct coding for spine and orthopedic-specific procedures (e.g., spinal fusions, joint replacements, etc.).Dispute Resolution:- Investigate and resolve issues related to out-of-network reimbursement rates, particularly for spine and orthopedic procedures, ensuring fair reimbursement according to industry standards or contracted rates.- Negotiate with insurance companies to secure appropriate payment for complex and high-cost spine/orthopedic services.- Maintain an understanding of orthopedic and spine treatment codes and payer policies to advocate effectively for claims.Patient Communication:- Work with patients to explain their billing statements, including detailed breakdowns of spine and orthopedic services and out-of-pocket responsibilities for out-of-network procedures.- Provide assistance in setting up payment plans or alternative billing arrangements for patients with outstanding balances, especially those for high-cost spine/orthopedic treatments.Documentation and Reporting:- Maintain accurate and up-to-date records of all billing and collection activities, specifically related to spine and orthopedic services.- Prepare detailed reports on outstanding claims, denials, appeals, and aging reports for management review.Insurance Reconciliation:- Reconcile payments received from commercial carriers, comparing payments against claims submitted for spine/orthopedic services to identify discrepancies.- Ensure that correct adjustments are made and appropriate write-offs are processed in accordance with established policies for specialized procedures.Required Skills and Qualifications:Experience: - Minimum of 5+ years of experience in medical billing and collections, with specific experience handling commercial insurance carriers (e.g., Blue Cross Blue Shield, Aetna, United Healthcare) and out-of-network claims.- Previous experience working with orthopedic and spine-related procedures (e.g., spinal fusions, joint replacements, disc replacements, etc.) is a significant plus.- Familiarity with ICD-10, CPT, and HCPCS coding related to orthopedic/spine treatments.- Strong understanding of out-of-network and payer reimbursement structures, and orthopedic-specific reimbursement issues.Technical Proficiency:- Proficient in using medical billing software (e.g., Modmed).- Experience working with electronic health record (EHR) systems and claims management tools.- Knowledge of HIPAA regulations and confidentiality protocols.Communication Skills:- Strong verbal and written communication skills to interact professionally with insurance carriers, healthcare providers, and patients.- Ability to explain complex billing and insurance information in a clear and concise manner, especially in the context of orthopedic/spine procedures.Problem Solving:- Strong analytical skills to identify trends, resolve billing discrepancies, and address issues specific to orthopedic and spine claims.- Ability to manage multiple priorities in a fast-paced environment and meet deadlines.Education: - High school diploma or equivalent required; Associate’s or Bachelor’s degree in healthcare administration, business, or related field preferred.Work Environment:- Office-based standard working hours.- Standard working hours, with occasional overtime required to meet deadlines or resolve urgent claims.Pay Transparency Statement:In accordance with the New Jersey Pay Transparency Act, this role falls within Pay Grade 7 of the 2025 OPM Salary Table for the NY, NJ, CT, and PA region. Compensation is commensurate with experience and education.

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