Role Description We are looking for a highly detailed, collaborative, and Bilingual Medical Biller - Referral and Eligibility Specialist to join our growing orthopedic billing department. This role focuses heavily on the front-end revenue cycle, serving as our primary defensive line against insurance denials by mastering insurance verification, eligibility auditing, and referral acquisition before the patient ever steps into the clinic. Operating across four busy office locations, your primary directive is to bridge the communication gap between all stakeholders in the patient's care. On any given day, you will act as a core liaison—collaborating in real-time with our internal front desk teams to resolve coverage discrepancies, communicating empathetically with patients to clarify complex insurance rules, and proactively contacting outside Primary Care Physician (PCP) clinics and insurance providers to secure required electronic referrals. To thrive in this role, you must possess a deep understanding of U.S. commercial and government payer structures, a relentless eye for detail, and the ability to maintain fluid, professional communication across high-volume networks. Qualifications - 2–3+ years in U.S. healthcare focused on insurance verification, eligibility auditing, and electronic referrals. - Strong understanding of commercial/government payers, coordination of benefits (COB), and orthopedic billing workflows. - Proven ability to manage a heavy workload across multiple clinic locations simultaneously. - Ability to manually audit EMR data to catch and fix insurance discrepancies 24–48 hours before patient arrival. - Native or professional fluency in both English and Spanish (written and verbal). - Experience calling external PCP clinics and insurance companies to secure missing documentation. - Working knowledge of portal-based electronic referrals (Availity, UHC, Cigna, etc.) and an understanding that paper notes are not sufficient. - Ability to explain complex insurance terms to patients simply and empathetically, especially those in physical pain. Requirements - Efficiently manage and own the end-to-end insurance verification workflow for two of our four busy office locations, splitting total practice volume evenly with a partner specialist. - Manually audit and resolve complex eligibility discrepancies flags within the ModMed EMR 24 to 48 hours prior to patient arrival to preemptively catch front-end errors. - Meticulously audit and update patient accounts regarding critical financial metrics, including active/inactive insurance coverage, out-of-pocket maximums, copays, and remaining deductibles. - Initiate direct contact with commercial and government insurance payers to manually verify complex benefits, and proactively call patients whose coverage flags as inactive to update their records. - Secure valid electronic referrals directly from Primary Care Physicians (PCPs) utilizing online insurance portals (e.g., Availity, UHC, Cigna). - Actively build rapport with external PCP clinics and insurance companies to trace, retrieve, and attach missing referrals—ensuring zero claims are denied for "missing referral on file." - Translate confusing insurance jargon into simple, digestible information for patients. Clearly explain what an electronic referral is and why major payers like Aetna and Anthem mandate it before seeing an orthopedic specialist. Benefits - A secure, quiet home office with high-speed internet, a professional noise-canceling headset, and a secondary monitor (preferred). Preferred Qualifications - Hands-on experience using Modernizing Medicine (ModMed / EMA / PM) software. - Prior experience working in an Orthopedics, Physical Therapy, or Sports Medicine outpatient clinic.

• Diagnose, troubleshoot, and repair computer hardware and system components • Replace defective parts and perform hardware installations and upgrades • Collect and communicate technical data to support teams for escalations and project planning • Follow established service procedures and documentation standards • Deliver excellent on-site support and maintain positive client relationships

• Provide disability case management and claim determinations based on complex medical documentation • Analyze, approve and authorize assigned claims and determine benefits due pursuant to a disability plan • Communicate clearly with claimant and client on all aspects of claims process

• To provide world class customer service and service delivery to our clients and patients through processing referrals in the delivery of medical goods and services. • Reaches out to patients in relation to new or already processing referrals confirming patient demographic information, providing updates on the referral, and/or confirming delivery of said goods or service. • Communicates with vendor partners, claims adjusters and nurse case managers providing updates on new referrals as well as referrals already in process. • Procures vendor partners for each referral as it relates to the goods or services requested. • Responsible for making or taking phone calls on existing referrals, new referrals, or other team members referrals. • Provides quotes back to clients for approval or follow up on quotes already sent to obtain written approval for requested referrals ensuring that each referral is deemed medically necessary and approved by the claim’s adjuster. • Confirms all required and relevant billing information exists in each referral as it relates to the workflow and billing processes in place and moves those referrals to be billed each day. • Processes referrals per state regulations and workers compensation guidelines.