Billing Specialist

Job Summary

The MCO Billing Specialist is responsible for the accurate and timely billing, follow-up, and collection of claims submitted to managed care organizations. This role ensures compliance with payer-specific requirements, resolves claim denials and rejections, and supports the organization's revenue cycle by minimizing aging accounts receivable.

Responsibilities

• Prepares, reviews, and submits clean claims to managed care payers via electronic and paper submission
• Verifies member eligibility, benefits, and authorization requirements prior to claim submission
• Researches, corrects, and resubmits denied, rejected, or underpaid claims within payer timely-filing limits
• Posts payments, adjustments, and denials
• Reconciles remittance advices (ERA/EOB) against expected reimbursement.
• Monitors accounts receivable aging and conducts proactive follow-up on outstanding claims
• Maintains current knowledge of payer contracts, fee schedules, and MCO-specific billing rules
• Communicates with payers, providers, and internal departments to resolve billing discrepancies
• Documents all account activity accurately in the billing/practice management system.
• Ensures compliance with HIPAA, payer guidelines, and applicable state and federal regulations
• Assists with month-end reporting and identifies trends in denials or reimbursement issues
• Consults with claim clerks at each MCO about any disputed claims and follows up on all bills not processed within the usual claim period.
• Prepares weekly and monthly reports of MCO billing

Competencies

Attention to detail, analytical problem-solving, organization, and clear written/verbal communication.