Billing and Claims Specialist

About Company:

As one of the largest primary care practices in Southwest Georgia, Albany Area Primary Health Care (AAPHC) provides health care services to more than 54,000 patients and nearly 217,000 office visits per year. AAPHC is also one of the largest Community Health Centers in our region! To learn more about Community Health Centers, and how this benefits Southwest Georgia.

At AAPHC, we strive to provide comprehensive, coordinated, and continuous care to all who access our services. Did you know that all qualifying medical offices operated by AAPHC are recognized as a Level III Patient Centered Medical Home (PCMH) by the National Center for Quality Assurance (NCQA)? NCQA offers three levels of PCMH recognition with Level III being the highest level. As a Level III PCMH, AAPHC is committed to continuously raising the quality of care within our practices, while also lowering our patients health care costs.

Our health care teams are comprised of physicians, physician assistants, nurse practitioners, and nurse midwives. Assisting these providers are clinical staff members, laboratory personnel, and business office professionals.

Our goal is to always provide access, and even expand access, to your provider so you always can reach AAPHC when you need us most! When you visit an AAPHC office, you can trust that you'll be well cared for by our team. Always.

About the Role:

The Billing and Claims Specialist plays a critical role in ensuring the accurate and timely processing of patient billing and insurance claims within the healthcare industry. This position is responsible for managing patient accounts, reviewing claims for accuracy and compliance, and coordinating with insurance providers to resolve discrepancies. The specialist will work closely with healthcare providers, patients, and insurance companies to facilitate smooth financial transactions and optimize reimbursement processes. By maintaining detailed records and adhering to regulatory standards, the role supports the financial health of the organization and enhances patient satisfaction. Ultimately, the Billing and Claims Specialist contributes to the efficient operation of billing systems and the reduction of claim denials and delays.

Minimum Qualifications:

• High school diploma or equivalent; associate degree or higher in healthcare administration or related field preferred.
• Minimum of 3 years experience in patient account management, billing operations, or claims processing within a healthcare setting.
• Strong knowledge of medical billing procedures, insurance claim processes, and healthcare regulations.
• Proficiency with billing software and electronic health record (EHR) systems.
• Excellent communication and organizational skills.

Preferred Qualifications:

• Certification in medical billing and coding (e.g., CPC, CCA) or related credentials.
• Experience working with multiple insurance providers including Medicare and Medicaid.
• Familiarity with HIPAA compliance and healthcare privacy laws.
• Advanced proficiency in data analysis and reporting tools.
• Prior experience in a hospital or large healthcare facility environment.

Responsibilities:

• Manage and maintain patient account information, ensuring accuracy and confidentiality.
• Review and process insurance claims, verifying coding, coverage, and patient eligibility.
• Communicate with insurance companies to resolve claim denials, rejections, or discrepancies.
• Collaborate with healthcare providers and administrative staff to gather necessary documentation for claims.
• Monitor billing operations to ensure compliance with healthcare regulations and organizational policies.
• Prepare and submit timely billing statements to patients and insurance carriers.
• Perform write-offs according to AAPHC financial policies and escalate account issues to the Insurance Director.
• Establish and maintain rapport with insurance companies and agencies to facilitate corrections and resolution of denied claims.
• Maintain open communication with managers and front-desk staff to share relevant updates or payer information.
• Perform other duties as assigned to support departmental and organizational goals.
• Track claim status and follow up on unpaid or underpaid claims to maximize reimbursement.
• Maintain detailed records of billing activities and claim resolutions for auditing purposes.

Skills:

The required skills such as patient account management, claims review, and billing operations are utilized daily to ensure that patient billing is accurate and compliant with healthcare standards. The specialist uses patient account management skills to maintain up-to-date and precise financial records, which are essential for effective billing and claims processing. Claims review skills are critical for identifying errors or inconsistencies in insurance submissions, enabling timely corrections and reducing claim denials. Billing operations expertise supports the coordination of billing cycles, statement generation, and payment tracking, ensuring smooth financial workflows. Preferred skills like certification and familiarity with healthcare regulations enhance the specialist’s ability to navigate complex insurance requirements and improve reimbursement outcomes.