Job Description

We are seeking an experienced, full-time Virtual Medical Biller / Insurance Verification Specialist for a busy Pain Treatment Center to optimize billing efficiency and aggressively reduce a 15% claim denial rate. Operating within the Prognosis EMR (with an upcoming transition to AdvancedMD) and utilizing the Weave phone system, this remote role independently manages front-end benefits verification, secures complex prior authorizations for specialized procedures, conducts pre-submission claim audits, and manages appeals.

Requirements

Roles and Responsibilities

1. Insurance Verification & Prior Authorizations (Primary Focus)

• Benefits Verification: Pre-verify patient insurance eligibility, deductibles, copays, and coinsurance prior to scheduled visits.
• Prior Authorizations & Referrals: Compile clinical documentation to submit and track authorizations for pain injections, imaging, and procedures.
• Proactive Review: Identify coverage exclusions or coordination of benefits (COB) issues before care is delivered to mitigate financial risk.

2. Medical Billing & Denial Management

• Pre-Submission Audits: Review outpatient claims for completeness and correct coding modifiers to maximize clean claim rates.
• Denial Investigation: Research, correct, and appeal denied or underpaid claims, tracking root causes to lower the practice's 15% denial trend.
• Payer Communication: Follow up consistently with Medicare, commercial carriers, and Workers' Compensation adjusters to resolve outstanding aging balances.

3. Administrative Support & Systems Navigation

• EMR Data Integrity: Document detailed coverage limits, authorization numbers, and billing updates accurately within the EMR.
• Telephony Coordination: Utilize the Weave platform to manage inbound/outbound calls and text routing regarding patient financial clearings.
• Schedule Adherence: Maintain highly reliable, independent productivity across a standard Monday through Friday, 8:00 AM – 5:00 PM PST shift.

Qualifications

• Experience: Minimum 2 years of dedicated medical billing, insurance verification, or authorization experience.
• Specialty Knowledge: Background working within a Pain Management, Interventional Pain, Spine, Orthopedic, or Physical Medicine practice.
• Language Proficiency: Exceptional written and verbal English communication skills for insurance negotiations and patient discussions.

Preferred Skills

• Direct experience with AdvancedMD (highly preferred) and/or Prognosis EMR systems.
• Strong familiarity with billing rules for Medicare, commercial carriers, and Workers' Compensation.
• Demonstrated track record of successfully reducing provider claim denials and improving reimbursement performance.

Work Style

• Analytical & Detail-Oriented: Catches formatting or diagnostic errors before claims leave the system.
• Proactive Problem-Solver: Addresses authorization roadblocks early rather than waiting for a claim to deny.
• Accountable: Takes complete ownership of core billing metrics with minimal supervision.