Denti - Cal & Medicaid Billing Specialist

Job Summary

The Denti-Cal & Medicaid Billing Specialist manages the full billing cycle for government dental programs across BOND's footprint : California Medi-Cal orthodontic claims under the Denti-Cal program, plus state Medicaid orthodontic billing for Apple Health (WA), Texas Medicaid (TMHP), Utah Medicaid, AHCCCS (AZ), Idaho Medicaid, Montana Medicaid, Alaska Medicaid, and Nevada Medicaid. The role requires working knowledge of each program's prior authorization requirements, treatment eligibility criteria, claim submission rules, fee schedules, and appeals processes, including deep familiarity with Denti-Cal's requirements and the DHCS appeals process.

This is an on-site position based at BOND's Frisco, TX headquarters. In-person presence is essential given the volume of real-time coordination required with RCM leadership and practice teams across nine states and four time zones, the complexity of Denti-Cal and multi-state Medicaid workflows, and the need for immediate communication on prior authorizations and appeals.

The Denti-Cal & Medicaid Billing Specialist plays a key role in executing the standards, policies, and procedures that support BOND Orthodontic Partners' Mission and Core Values.

Duties and Responsibilities:

The following is a list of specific duties which are essential functions of this job. The list is not exhaustive, as all duties are subject to change. Note that while the practice may provide an addendum to this job description that outlines some responsibilities specific to the practice needs, it does not replace this job description. While an effort has been made to describe the customary way this job is performed thoroughly, reasonable accommodation will be made upon notification for qualified individuals with disabilities who may not be able to perform the job in the manner indicated.

Summary of Essential Job Functions:

Denti-Cal Claims & Prior Authorization (California)

• Submit Denti-Cal prior authorization requests and orthodontic claims accurately and on time across all California practice locations.

• Interpret and apply Denti-Cal's Handicapping Labio-lingual Deviation (HLD) criteria to assess orthodontic treatment eligibility.

• Process TAR (Treatment Authorization Request) submissions and monitor approval status.

• Stay current on Denti-Cal policy updates, fee schedules, and billing guidelines issued by the California Department of Health Care Services (DHCS).

• Communicate effectively with DHCS and Denti-Cal fiscal intermediaries to resolve claim issues.

Multi-State Medicaid Claims & Prior Authorization

• Submit prior authorizations and Medicaid orthodontic claims accurately and on time across all assigned states (WA, TX, UT, AZ, ID, MT, AK, NV).

• Understand and apply each state program's orthodontic eligibility criteria, including HLD-equivalent scoring where applicable.

• Stay current on policy updates, billing guidelines, and fee schedule changes for each applicable state Medicaid program.

• Coordinate with state Medicaid fiscal agents and managed care organizations (MCOs) as needed to resolve claim issues.

• Track and manage prior authorization timelines across all programs, follow up on pending decisions, and communicate outcomes to practice teams promptly.

Claims Processing & Denial Management

• Review and audit claims for accuracy before submission; identify and correct errors that could result in rejection or denial.

• Conduct weekly audits of automated billing workflows including AI-based claim scrubbing and RPA-driven processes.

• Review Explanation of Benefits (EOBs) and Remittance Advice documents to verify payment accuracy and identify underpayments or incorrect denials.

• Manage denials and appeals across all assigned programs, including formal written appeals to DHCS and State Hearings for Denti-Cal claims and formal written appeals to state Medicaid programs where warranted.

• Identify denial trends by program and state; surface recommendations to the Director of RCM to improve first-pass acceptance rates.

• Enter contractual adjustments and process non-appealable denials in accordance with BOND guidelines.

Accounts Receivable & Reporting

• Maintain accurate account ledgers and ensure timely resolution of government program and patient balances across all assigned states.

• Generate and review insurance and patient aging reports; escalate and resolve outstanding balances.

• Meet or exceed the industry standard of working 50–60 accounts per day while maintaining a quality score of 80% or above.

Practice Coordination & Communication

• Serve as the primary billing resource for practice teams across all assigned states on Denti-Cal and Medicaid questions, workflows, and escalations.

• Partner with front office staff on eligibility verification, documentation requirements, and patient financial communications.

• Provide outstanding service through professionalism and empathy in all patient and practice interactions.

Compliance & Confidentiality

• Ensure all billing activity complies with Denti-Cal program requirements, applicable state Medicaid program requirements, HIPAA, and BOND internal policies.

• Maintain awareness of program and state-level compliance differences; flag potential compliance issues to the Director of RCM.

• Maintain confidentiality of all protected health information (PHI) consistent with HIPAA's minimum necessary standard.

• Perform other duties as assigned.

Knowledge and Skills:

• Strong working knowledge of Denti-Cal billing, prior authorization, and the DHCS appeals process, including HLD scoring and Medi-Cal orthodontic eligibility requirements.

• Working knowledge of Medicaid orthodontic billing in one or more of the following states: WA, TX, UT, AZ, ID, MT, AK, NV.

• Familiarity with multiple state Medicaid portals, fiscal agents, and MCO billing requirements strongly preferred.

• 1–3 years of orthodontic or dental billing experience required; Denti-Cal and/or multi-state Medicaid billing experience strongly preferred.

• Proficiency with dental practice management software; Ortho2Edge experience a plus.

• High attention to detail with the ability to manage a high-volume, multi-state workload accurately.

• Self-directed with the ability to prioritize and manage multiple program and state queues simultaneously.

• Strong written and verbal communication skills; comfortable supporting practice teams across multiple time zones.

• Problem-solving mindset with a patient-first approach.

• Ability to build trust and work cross-functionally with practice teams and department leadership.

Work Environment

This job operates in a professional office environment. This role routinely uses standard office computer equipment such as computers, laptops, and printers.

Physical Demands

The physical demands described here represent those that an employee must meet to perform the essential functions of this job successfully.

Most of the time will be spent on the computer and phone. Must be able to sit for long periods of time.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday, 8:00 a.m. to 5 p.m. CT. Flexibility in hours is required, as support may be necessary outside of the core hours.

HIPAA & THE MINIMUM NECESSARY STANDARD

The Employee shall maintain the confidentiality of all protected health information (PHI) whether electronic, written or oral to which he/she may be exposed either during the course of their duties or the result of an incidental disclosure. In accordance with the minimum necessary standard, the employee may only access PHI to perform the job.

o View, create, add, and modify all clinical and demographic protected health information.

o Disclose clinical and/or demographic protected health information for the purpose of patient treatment, healthcare operations and/or payment for services.

o Disclose all protected health information for any authorized purpose.

o The minimum necessary standard must be applied in all matters and shall continue privacy protection during non-working hours and after employment is no longer with the company.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.