Medical Billing Claims & Denials Specialist

We are seeking a detail-oriented and results-driven Accounts Receivable & Claims Resolution Specialist to join our Revenue Cycle Management team. This role involves managing outstanding insurance receivables, investigating claim denials, resolving payment discrepancies, and following up on unpaid or underpaid claims to enhance reimbursement outcomes. The ideal candidate will have a strong understanding of U.S. healthcare billing, insurance claims processing, denial resolution, and payer reimbursement procedures. Effective communication, analytical skills, and a proactive approach to claim management are essential for success in this position.

Key Responsibilities

- Monitor and manage outstanding insurance accounts receivable to improve collections, reduce aging, and support timely reimbursement.
- Conduct regular follow-ups on denied, rejected, pending, unpaid, and underpaid insurance claims.
- Review Electronic Remittance Advice (ERA), Explanation of Benefits (EOB), payer correspondence, and claim records to identify denial reasons, payment discrepancies, and reimbursement issues.
- Investigate claim denials and determine corrective actions such as claim corrections, resubmissions, reconsiderations, and appeals.
- Prepare, submit, and track appeals with complete clinical, coding, and billing documentation within payer deadlines.
- Research underpayments, coordination of benefits issues, authorization denials, medical necessity concerns, and other claim discrepancies.
- Analyze claim histories and payer responses to identify recurring denial patterns and recommend corrective measures.
- Maintain ownership of assigned accounts, ensuring consistent follow-up until resolution or escalation.
- Escalate complex or significantly aged accounts to Revenue Cycle leadership as needed.
- Maintain accurate accounts receivable aging reports and provide updates on collections, appeal status, denial trends, and account resolution.
- Manage billing and reimbursement follow-ups for specialized behavioral health services including Transcranial Magnetic Stimulation (TMS), Spravato, psychological evaluations, and other treatments.
- Collaborate with Revenue Cycle leadership to improve cash collections, reduce denials, and meet departmental performance goals.
- Communicate with insurance carriers to obtain claim status updates, clarify denial reasons, and resolve reimbursement issues.
- Work with providers and clinical teams to address coding discrepancies, missing documentation, medical necessity, and authorization barriers.
- Review patient and insurance account details for discrepancies in demographics, coverage, authorizations, and billing information.
- Coordinate account corrections, adjustments, refunds, rebilling, and other financial updates following established procedures.
- Respond professionally to billing inquiries from patients, providers, insurance representatives, and internal departments.
- Document all payer communications, claim updates, appeal submissions, and resolution outcomes accurately.
- Establish and maintain structured follow-up schedules to ensure timely claim resolution.
- Create, track, and resolve billing and claim-related support tickets within eClinicalWorks (eCW) and other revenue cycle platforms.
- Coordinate with U.S.-based billing and Revenue Cycle teams to support claim submission, payment posting, denial management, appeals, and reimbursement.
- Monitor key performance indicators such as AR aging, collection performance, denial rates, appeal outcomes, and resolution turnaround times.
- Conduct routine account audits to identify aging claims, recurring payer issues, and revenue recovery opportunities.
- Participate in departmental meetings, quality assurance activities, audits, and workflow improvement initiatives.
- Stay updated on payer policy changes, billing and coding requirements, reimbursement guidelines, authorization procedures, and healthcare regulations.
- Recommend improvements to claim follow-up workflows, denial prevention, documentation practices, and account management processes.
- Maintain patient confidentiality and ensure compliance with HIPAA and regulatory standards.

Required Qualifications

- Strong knowledge of U.S. medical billing, insurance claims processing, accounts receivable, denial management, appeals, and revenue cycle operations.
- Working understanding of commercial insurance, Medicare, Medicaid, payer reimbursement policies, and appeal procedures.
- Ability to interpret ERA/EOB information, denial codes, payer correspondence, payment variances, and reimbursement discrepancies.
- Proficiency in eClinicalWorks (eCW), practice management systems, payer portals, clearinghouses, ERA/EOB tools, and revenue cycle reporting platforms.
- Excellent analytical, investigative, critical-thinking, and problem-solving skills.
- Strong attention to detail when reviewing claims, payment records, and supporting documentation.
- Effective written and verbal communication skills for interacting with insurance representatives, providers, patients, and internal teams.
- Strong organizational and time-management abilities to handle multiple accounts, priorities, and deadlines.
- Ability to work independently and collaboratively within cross-functional teams.
- Commitment to patient confidentiality, HIPAA compliance, and healthcare billing regulations.

Preferred Qualifications and Additional Information

- Experience in behavioral health billing or specialty healthcare revenue cycle management is highly preferred.
- Minimum of 1 year of experience in accounts receivable or medical billing is preferred.
- Fluency in English is required.
- This position requires in-person work at the Wapda Town location, with reliable commuting or relocation plans.
- Candidates must be willing to work night shifts as part of the role.
- Monthly compensation ranges from Rs45,000 to Rs80,000 based on experience and qualifications.

This role offers the opportunity to contribute significantly to revenue recovery and reimbursement efficiency within a dynamic healthcare environment.