The specialist will act as a billing detective, analyzing denials, investigating claim issues, and resolving discrepancies to secure payments from payors. They must also collaborate effectively with clients and teammates while maintaining professional, trust-based relationships.

The representative will manage patient accounts by handling inbound patient calls, answering emails, making outbound collection calls, processing payments, and establishing payment plans. Key duties also involve researching balance issues, serving as a liaison, and processing accounts within the Electronic Medical Record system.

The specialist streamlines insurance processes by handling medication authorizations, conducting benefits investigations, and identifying financial assistance programs for patients. Key duties include gathering prior authorization details, supporting appeals for coverage denials, and communicating medication options and financial resources to patients.

The incumbent will analyze medical records and charts using clinical and coding expertise to evaluate the appropriateness of provider coding, reporting relevant data to the Centers for Medicare and Medicaid Services (CMS). This role involves ensuring compliance with the CMS Hierarchical Condition Category (HCC) payment methodology and developing professional relationships with providers to facilitate onsite record reviews.