Senior Medical Billing Specialist

Claims Submission & Daily Billing Operations

• Prepare and submit clean claims on a continual basis for all service lines (ECM, Community Supports, Housing Navigation, etc.), ensuring timely submission.
• Validate all claims against clinical documentation in , including encounter notes, service timelines, eligibility, and required fields.
• Monitor daily clearinghouse reports for rejections and errors; correct and resubmit promptly.
• Maintain claims submission schedules to meet payer deadlines and internal billing cycles.
• Take full ownership of denials, rejections, and unpaid claims—ensuring root-cause resolution and successful resubmission.
• Contact payers directly to resolve issues related to authorizations, eligibility, coding, coordination of benefits, missing documentation, and system errors.
• Work with the clearinghouse to identify transmission issues, file format errors, and claim routing problems.
• Document all denial reasons, corrective actions, and payer communications in internal trackers.
• Analyze denial trends and escalate systemic issues to the Revenue Cycle Manager.
• Ensure corrected claims are resubmitted within required payer timelines.

Documentation & Clinical Validation

• Cross-check claims against clinical encounters to ensure documentation supports the billed service.
• Verify all required data elements (encounter type, duration, service location, care manager documentation, and signatures) meet payer and CalAIM compliance requirements.
• Flag and communicate documentation gaps to the care team and Revenue Cycle Manager.
• Assist in quality assurance reviews of clinical documentation and coding completeness.

Revenue Cycle & Reporting Support

• Maintain accurate billing logs, denial trackers, and A/R aging reports.
• Support month-end reconciliation of payments, adjustments, and unresolved claims.
• Assist in preparing reports on claim submission volumes, denial rates, payer trends, and days-in-A/R.
• Contribute to continuous improvement of RCM workflows, SOPs, and billing policies.

Cross-Department Coordination

• Collaborate with Authorization Specialists to verify approval status before billing.
• Communicate frequently with Care Managers, Supervisors, and the Admissions team to ensure all required documentation is available for compliant billing.
• Provide feedback to clinical teams on common documentation or encounter issues that delay billing.
• Participate in RCM meetings and trainings to maintain alignment across teams.