GENERAL POSITION SUMMARY:
The CalAIM Billing Specialist is responsible for overseeing the full revenue cycle for CalAIM services, including Enhanced Care Management and Community Supports. This position ensures the accurate and timely verification of member eligibility, authorization management, claim preparation and submission, payment reconciliation, denial resolution, and compliance with Department of Health Care Services, Medi-Cal, and Managed Care Plan requirements. The Billing Specialist serves as the primary liaison between program staff, fiscal staff, electronic health record systems, and managed care organizations to ensure services are appropriately documented, authorized, billed, and reimbursed.
ESSENTIAL JOB RESPONSIBILITIES:
PERFORMANCE INDICATORS
Claims Processing & Billing
- Verify Medi-Cal and managed care eligibility daily.
- Prepare and submit accurate and timely claims to Medi-Cal managed care plans for ECM and CS services.
- Ensure proper use of billing codes and compliance with CalAIM billing standards.
- Monitor claim submissions; track rejections, denials, or pending claims and follow up promptly to resolve issues.
Authorization & Documentation Tracking
- Track and verify Treatment Authorization Requests (TARs) for all billable services.
- Ensure billed services are supported by valid documentation and approved authorizations.
- Coordinate with program and clinical staff to address missing or incomplete documentation.
Reconciliation & Payment Posting
- Post payments received from managed care plans and reconciled against submitted claims.
- Investigate and resolve underpayments, denials, or delays in reimbursement.
- Maintain accurate and up-to-date financial and billing records.
Compliance & Audit Support
- Stay current with DHCS, Medi-Cal, and managed care billing regulations and updates.
- Conduct internal audits of service documentation to ensure billing compliance.
- Prepare and provide necessary reports and documentation for audits, compliance reviews, and internal monitoring.
Coordination & Communication
- Collaborate closely with ECM case managers, CS providers, and finance staff to ensure billing accuracy.
- Educate and guide program staff on documentation and billing requirements.
- Communicate with health plans to resolve discrepancies, denials, or claim issues.
Reporting & Analysis
- Maintain accurate billing logs, tracking systems, and submission reports.
- Generate regular billing and financial performance reports for leadership.
- Analyze trends and recommend improvements to enhance billing efficiency and reimbursement rates.
SECONDARY FUNCTIONS:
- Conduct routine outbound calls to members, as assigned, to support appointment reminders, eligibility verification, required program follow-up, and other administrative activities that promote member engagement and continuity of services.
- Document member outreach activities in the electronic health record and communicate pertinent information to the assigned Case Manager.
- Attends training and informational meetings as directed.
- Maintains confidentiality with respect to information and records concerning clients, and staff.
- Other duties as assigned within the scope of position classification.
MINIMUM REQUIREMENTS:
- High school diploma or GED required.
- One year of experience in an administrative, customer service, medical office, billing, accounting support, or related office environment preferred.
- Experience working with electronic health records (EHR), databases, or billing systems is preferred but not required.
- Strong computer skills, including Microsoft Outlook, Word, Excel, and the ability to learn new software systems.
- State regulations require a physical examination, current tuberculosis test, and verified
fingerprint and criminal records clearance before beginning work.
- Possession of a valid drivers' license; current personal vehicle insurance or safe driving record sufficient to ensure insurability through Agency policy.
KNOWLEDGE, SKILLS, AND ABILITIES:
- Ability to organize and prioritize multiple tasks while maintaining a high level of accuracy and attention to detail.
- Ability to maintain confidentiality and handle sensitive client and financial information in accordance with HIPAA and agency policies.
- Ability to write reports, business correspondence, and procedure manuals.
- Ability to effectively present information and respond to questions from groups of parents, employees of the organization, and the general public.
- Previous experience and familiarity with nonprofit fund accounting and experience in budget development is desirable.
- Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions and decimals.
- Ability to compute rate, ratio and percent.
- Ability to apply generally accepted accounting principles to routine activities.
- Ability to understand and use a variety of computer applications and appropriate software, including spreadsheets and word processing; and workplace electronic technology, including internet access and e-mail.
This job description is not a contract for employment. Duties may be changed at the Administration’s discretion. The employee is expected to do other duties as assigned, which obviously fall within the scope of this job.
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discrimination on the basis of race, color, national origin, sex, sexual orientation, age, or disability.
Pay: $22.50 - $28.71 per hour
Benefits:
- Dental insurance
- Employee assistance program
- Health insurance
- Paid time off
- Retirement plan
- Vision insurance
Application Question(s):
- Are you available to work on site?
Work Location: In person
