CalAIM Medical Billing & Claims Coordinator

Description

Job Summary: Under the direction and supervision of the CalAIM QA/Compliance Manager or Regional Director, the Medical Billing and Claims Coordinator is responsible for assisting with the planning and coordinating of billing and claims processing for the CalAIM Programs division. This position ensures the timely and accurate medical/healthcare claims preparation, submission/resubmission process, resolution of issues, as well as compliance with the billing claims policies and guidelines of DHCS Managed Care Plans (MCPs). The Medical Billing and Claims Coordinator provides timely internal communications with leaders, compliance training for staff, and process improvement recommendations through quality assurance monitoring. The position also handles billing data input and ensures compliant billing practices, accurate coding, adherence to regulations, maintenance of accurate billing reports, and performance of internal audits. A strong collaborator, the Medical Billing and Claims Coordinator will work with the Finance and Compliance Departments, internal CalAIM leadership and regional teams, and external stakeholders including MCPs and network partners to coordinate and facilitate efficient CalAIM billing claims activities. Their analytical abilities, attention to detail, and strong communication skills contribute to CalAIM Program’s success and LSS’s mission to embrace, equip, and empower individuals, families, and communities toward self-sufficiency.

Requirements

Essential Duties and Responsibilities include the following. Other duties may be assigned.

•Serves as primary technical resource for billing process improvement and troubleshooting.

•Creates data collection forms and proficiently utilizes software (i.e., Excel spreadsheets and other software programs).

•Maintains organized and up-to-date records of all billing and claims activities. Ensures that proper documentation is retained for auditing and reporting purposes.

•Submits the data to billing within Medi-Cal Health plan’s guidelines.

•Communicates with the Finance Department to report CalAIM program billing data monthly.

•Collaborates with the Finance Department to analyze, problem-solve, and reconcile invoices.

•Manages the documentation of receipts through the CalAIM Deposit services and maintains accurate documentation of these records within the portal.

•Completes billing for Medi-cal billing plans such as Anthem Blue Cross Medi-Cal, Health Net Medi-Cal, L.A. Care Health Plan Medi-Cal, Molina Healthcare Medi-Cal, Kaiser Permanente Medi-Cal, Blue Shield of California Promise Health Plan Medi-Cal, and other MCPs.

•Performs data processing and data imports into and within the medical Billing system(s).

•Demonstrates proficiency in medical billing software and electronic health records (EHR). Availity, Office Ally, Health Net, Conduent, Kareo, eClinicalWorks, Athenahealth, NextGen Healthcare, Cerner, Allscripts, MediTouch EHR

•Possesses in-depth knowledge of insurance processes, including verification, pre-authorization, and claims appeal procedures.

•Assists with configuration and maintenance of medical Billing System software in accordance with applicable regulations and insurance payer rules.

•Assists in analyzing and resolving EDI claim and remittance file issues

•Works with billing staff to support follow-up on bundled services and denials related to services provided and reviews all appeals to ensure documentation supports coding.

•Provides training to the CalAIM program and LSSSC staff to improve coding outcomes.

•Provides training and orientation to new staff regarding billing, data, and systems.

•Analyzes, problem-solve, and resubmit claim rejections and denials.

•Performs and review Medi-Cal, Medicare, and Cal MediConnect eligibilities.

•Other duties may be assigned.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below represent knowledge, skill, and/or ability. Reasonable accommodation will be made to enable individuals with disabilities to perform essential functions.

Education/Experience: Bachelor’s degree in healthcare administration, Business, or related field (or equivalent experience) preferred, and 2-3 years of experience in medical billing, with specific knowledge of CalAIM billing procedures and regulations for Medi-Cal insurance health plans, and/or other applicable billing regulations (Medi-Cal, Medicare, Insurance). Proficiency in billing and claims software/systems and accounting principles. Prior experience in medical billing and claims processing, preferably within a government healthcare program. Must hold a certification in medical billing and coding from an accredited organization such as AAPC or AHIMA.

Coding Proficiency: Proficient in ICD-10, CPT, and HCPCS coding systems, with a strong understanding of CalAIM-specific codes.

Software Skills: Familiarity with medical billing software, electronic health record (EHR) systems, and Microsoft Office Suite.

Attention to Detail: Exceptional attention to detail and accuracy in processing claims and maintaining records.

Communication: Excellent verbal and written communication skills, with the ability to interact professionally with patients, insurance companies, and internal staff.

Problem-Solving: Strong problem-solving skills and the ability to analyze billing issues and resolve discrepancies.

Ethical Conduct: Adhere to the highest ethical standards and maintain patient confidentiality.

Time Management: Effective time management skills to meet deadlines and prioritize tasks in a fast-paced environment.

Certificates and Licenses:

Relevant certificates such as Certified Professional Biller (CPB) or Certified Medical Reimbursement Specialist (CMRS) are strongly preferred.

Language Ability:

Must be able to read, write and speak fluent English. Ability to follow directions, policies, and procedures. Excellent verbal and written communication skills. Bilingual preferred but optional.

Math Ability:

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 and to draw and interpret bar graphs.

Reasoning Ability:

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations. Ability to anticipate problems before they occur and catch details that may fall through the cracks.

Computer Skills:

To perform this job successfully, an individual should know Word Processing and Spreadsheet software. Microsoft Office, Publisher

Work Environment:

The work environment characteristics described here represent those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.

The noise level in the work environment is usually moderate.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

The employee must regularly lift and /or move 25 pounds and up. Specific vision abilities required by this job include Close vision. While performing the duties of this job, the employee is frequently required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear.