Job Description
Job Description
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.