The Commercial Medical Biller is responsible for accurate and timely billing of hospital and Rural Health Clinic (RHC) claims to commercial insurance payers. This role focuses heavily on denial management, claim follow-up, and reimbursement optimization while ensuring compliance with payer contracts, federal regulations, and internal policies.
Billing & Claims Submission
Prepare, review, and submit hospital and RHC claims to commercial insurance carriers.
Ensure correct use of CPT, HCPCS, ICD-10, revenue codes, modifiers, and RHC-specific billing requirements.
Verify charges, units, dates of service, provider credentials, and place of service.
Submit corrected, adjusted, and late charges as needed.
Denial Management
Analyze and resolve billing denials, rejections, and underpayments.
Identify root causes of denials (coding, authorization, eligibility, medical necessity, bundling, timely filing, etc.).
Prepare and submit corrected claims and formal appeals with appropriate documentation.
Track denial trends and recommend process improvements to reduce future denials.
Insurance Follow-Up
Conduct timely follow-up with commercial payers on unpaid, underpaid, or delayed claims.
Communicate with insurance representatives to obtain claim status and resolution.
Maintain detailed notes and documentation in the billing system for all follow-up activity.
Meet productivity and follow-up benchmarks to ensure timely reimbursement.
Compliance & Collaboration
Ensure compliance with payer guidelines, hospital policies, and RHC billing regulations.
Work closely with coding, registration, authorization, and clinical staff to resolve billing issues.
Stay current on commercial payer policy updates and RHC billing changes.
Knowledge of hospital and RHC billing processes.
Strong experience with commercial insurance billing and denial resolution.
Proficiency in CPT, ICD-10-CM, HCPCS, and modifiers.
Familiarity with payer portals and claim management systems.
Strong analytical, organizational, and follow-up skills.
Ability to manage high-volume workloads with attention to detail.