WHAT DOES A MEDICAL BILLER DO?

Updated: Dec 18, 2025 - The Medical Biller prepares and submits clean claims to insurance companies, resolves billing errors, and posts insurance or patient payments to ensure accurate account reconciliation. This role involves researching denials, following up on unpaid or underpaid claims within timely filing limits, completing written appeals, and responding promptly to patient inquiries. The Biller also manages patient statements, performs collection actions, evaluates financial status to set up payment plans, and identifies accounts for possible referral to collection agencies.

A Review of Professional Skills and Functions for Medical Biller

1. Medical Biller Job Summary

  • Claims Follow-up: Call insurance companies for the status of outstanding claims.
  • Appeals Processing: Process and follow up on appeals to insurance companies.
  • Workflow Management: Manage workflows between the client and processing departments.
  • Efficiency Strategies: Utilize strategies for efficient and accurate results.
  • A/R Analysis: Analyze/Prioritize A/R for accounts to achieve best efficiencies.
  • Billing Knowledge: Understand billing concepts and document actions and activities in various applications.
  • Payer Portals: Work with payer web portals and other online claim status applications.
  • Client Interaction: Work with clients daily.
  • Account Auditing: Research/audit patient accounts for further payment and/or adjustments.
  • Productivity Standards: Meet productivity standards as set by the departments.
  • Code Review: Perform code corrections and evaluate EOB’s/ERAs.
  • Performance Targets: Achieve monthly targets for productivity and quality.

2. Medical Biller Accountabilities

  • Billing System Development: Develop an in-house billing system for hospitalist practice from the ground up, including selection of clearing house, provider enrollment, credentialing, etc.
  • Claim Submission: Prepare and submit clean claims for practice.
  • Collections Management: Perform various collection activities, including contacting patients by phone, correcting and resubmitting claims to third-party payers.
  • Payment Processing: Process payments from insurance companies and prepare a daily deposit.
  • Billing Resolution: Identify and resolve patient billing complaints.
  • Data Tracking: Maintain billing data metrics and logs for management.
  • Process Optimization: Identify the key billing process that is slow or reduces reimbursement.
  • Meeting Participation: Attend monthly meetings.
  • HIPAA Compliance: Maintain strictest confidentiality, adhering to all HIPAA guidelines and regulations.
  • Enrollment & Credentialing: Responsible for Provider Enrollment/Credentialing.

3. Medical Biller Functions

  • Data Entry: Enter patient demographic and insurance information in the system.
  • Patient Assistance: Provide information and assistance to patients to ensure they understand the Financial Assistance policy and application process.
  • Financial Review: Ensure that financial protocols and requirements are met while providing access to service at health system facilities by reviewing account documentation.
  • Cash & Admission Tasks: Perform cash collection functions (co-pay), admission, discharge, and transfer functions.
  • Insurance Verification: Maintain and apply current knowledge of insurance requirements when verifying eligibility and confirm authorization is secured before forwarding patients to service delivery areas.
  • Account Escalation: Escalate insecure financial accounts to management.

4. Medical Biller Job Description

  • Delinquent Account Collection: Collect delinquent accounts by establishing payment arrangements with patients, monitoring payments, and following up with patients when/if payment lapses occur.
  • Agency Collaboration: Work with collection agencies and small claims courts to collect on delinquent accounts.
  • Medicare Reporting: Maintain the Medicare bad-debt cost report by tracking billings, monitoring collections, and compiling information.
  • Operational Compliance: Maintain work operations by following policies and procedures; reporting compliance issues.
  • Confidentiality Protection: Protect ASC's value by keeping collection information confidential.
  • Standards Adherence: Adhere to professional standards, hospital policies and procedures, federal, state, and local requirements, and JCAHO standards.

5. Medical Biller Overview

  • Patient Data Accuracy: Ensure patient information is accurate and complete.
  • Information Retrieval: Request any missing patient information.
  • Referral Review: Review referrals and authorizations.
  • Benefit Verification: Confirm patient benefits and insurance.
  • Regulatory Compliance: Follow all regulations and guidelines set by Medicare, state programs, and HMO/PPO.
  • Data Transfer: Transfer insurance claims and billing data to the billing software.
  • Document Preparation: Create both paper and electronic copies of documentation.
  • Payment Tracking: Develop and maintain a tracking system of incoming and late payments.
  • Late Payment Monitoring: Monitor and date late payments.
  • Notice Initiation: Initiate late payment notices to relevant parties.
  • Inquiry Response: Respond to questions and complaints from patients or insurance companies.
  • Payment Follow-up: Follow up on late or missed payment notices.
  • Discrepancy Resolution: Monitor and resolve financial discrepancies.
  • Payment Arrangement: Arrange payment plans and timelines for payments.
  • Record Maintenance: File and maintain organized documentation of all billing and records.
  • Billing Procedures: Follow set billing processes and procedures.
  • Account Updating: Update and review all accounts to keep records of payments up-to-date.

6. Medical Biller Details and Accountabilities

  • Professional Appearance: Adhere to the dress code, and ensure appearance is neat.
  • Credential Maintenance: Maintain current license, registrations, and/or certifications.
  • Confidentiality Compliance: Maintain patient confidentiality at all times.
  • Attendance Reliability: Report to work on time.
  • Regulatory Adherence: Maintain regulatory requirements, including all state, federal, and local.
  • Professional Representation: Represent the organization positively and professionally at all times.
  • Ethical Compliance: Comply with all organizational policies and standards regarding ethical business practices.
  • Mission Communication: Communicate the mission, ethics, and goals of the company.
  • Quality Improvement: Participate in performance improvement and continuous quality improvement.

7. Medical Biller Tasks

  • Claim Preparation: Prepare insurance claims for submission to third-party payers and/or responsible parties.
  • Claim Accuracy Review: Review claims for accuracy, including proper diagnosis and procedure codes.
  • Rejection Resolution: Review claim rejections and communicate with payers to resolve billing issues.
  • Billing Reporting: Prepare and review routine billing reports.
  • Process Improvement: Recommend process improvements based on findings.
  • Inquiry Response: Respond to complex telephone and written inquiries from patients and/or third-party payers and physician practices.

8. Medical Biller Roles

  • Account Follow-up: Follow up and analyze patient accounts on an ongoing basis to maximize reimbursement.
  • Information Confirmation: Ensure that the insurance company has received all information.
  • Secondary Billing: Prepare accounts for secondary billing with EOB.
  • Adjustment Preparation: Prepare accurate contractual and administrative adjustments on appropriate accounts with backup to the Business Office Director for approval.
  • Timely Submission: Ensure claims are submitted to third-party payers on time.
  • Inquiry Handling: Answer telephone calls and respond to all inquiries (verbal and written) from guarantors and third-party payers.
  • Refund Review: Prepare and review all refund adjustments requested by insurance companies.
  • Payment Review: Review payments to ensure appropriate payment has been received and identify potential denials and take appropriate action.
  • Denial Communication: Relay any denials to Case Management and the Business Office Director for final determination.
  • Appeal Monitoring: Make sure that appropriate accounts are identified promptly for possible Midas placement and appeal, and document the status in Midas.

9. Medical Biller Additional Details

  • Claim Submission: Prepare and submit clean claims to various insurance companies either electronically or by paper.
  • Issue Resolution: Address issues that may prevent the timely payment of claims, such as billing errors.
  • Payment Posting: Post insurance and/or patient payments.
  • Account Reconciliation: Research denials, partial payments, and overpayments to reconcile patient accounts.
  • Claim Follow-up: Follow up on unpaid/underpaid claims within the timely filing limits.
  • Trend Reporting: Alert management to irregularities, patient trends, and areas of concern.
  • Appeal Preparation: Complete written appeals of claims that have been incorrectly paid by insurance companies.
  • Patient Response: Respond to patient inquiries promptly.
  • Statement Processing: Prepare/review and send patient statements.
  • Collection Actions: Perform various collection actions, including contacting patients by phone, correcting and resubmitting claims to secondary payors, etc.
  • Financial Evaluation: Evaluate the patient’s financial status and set up payment plans.
  • Collection Referral Review: Review accounts for possible referral to a collection agency.

10. Medical Biller Essential Functions

  • Batch Posting: Post daily encounter batches to the billing system.
  • Daily Balancing: Balance daily charges, adjustments, and payments.
  • Insurance Tracking: Track, update, and file patient insurance information.
  • Report Production: Produce required posting shift reports.
  • Statement Assistance: Assist in the preparation of private and industrial account statements.
  • Record Maintenance: Maintain current, complete, and accurate patient and procedure files in the billing system.
  • Denial Resubmission: Investigate and resubmit denials from insurance companies.
  • Professional Communication: Communicate with patients, coworkers, providers, and third-party representatives professionally.
  • Account Inquiry Response: Respond to questions regarding patient account balances.
  • Workflow Coordination: Daily interaction and communication with the Billing Supervisor to prioritize the workflow.

11. Medical Biller Role Purpose

  • Eligibility Verification: Run eligibility in third-party software to ensure the claims are going out to the correct payers.
  • Claim Submission: Submit claims to the clearinghouse (Medicaid and Medicaid Managed Care) and fix rejections.
  • Remit Management: Upload remits into the software and save files in the financial drive weekly, by program.
  • Denial Resolution: Work on denied claims and rebill on demand.
  • Billing Reporting: Together with the medical billing manager, provide billing reports to senior staff and enter data into Financial Edge.
  • Issue Tracking: Maintain the issue tracker between program and finance to ensure all corrections are made in a timely fashion.
  • Data Scanning: Scan completed data into the financial drive by program with a copy of the claim status report.
  • Billing Liaison: Serve as day-to-day liaison to the agency’s third-party billing company.
  • File Retrieval: Retrieve the monthly file from the FCA program and send it to the agency consultant who bills on behalf of the agency (PG software).
  • Remit Posting: Retrieve remits from eMEDNY, upload them into PG software, post to A/R, and work on denials for resubmissions.
  • Claim Production: Use coded data to produce and submit claims to Medicaid and insurance companies.
  • Claims Coordination: Work directly with Medicaid, insurance companies, healthcare providers, and patients to get claims processed and paid.
  • Appeal Support: Produce source material for the agency so they can review and appeal unpaid claims - Journal Entries, Cash Receipts, and Deposit Back-up.
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