Medical Billing Specialist

The CalAIM Medical Billing Specialist is responsible for managing the day-to-day administrative and billing operations related to Enhanced Care Management (ECM) and Community Supports (CS) services. This position supports the organization’s CalAIM programming by ensuring accurate claims submission, authorization management, billing compliance, encounter tracking, and reimbursement optimization in accordance with DHCS, Managed Care Plan (MCP), Medi-Cal, and organizational requirements.

The Billing Specialist works closely with care managers, housing support staff, leadership, and Managed Care Plans to ensure timely and compliant billing processes while maintaining accurate records within electronic medical records (EMR/EHR) and billing systems.

Qualifications:

• High school diploma or equivalent required; Associate’s degree in Medical Billing and Coding, Healthcare Administration, Business Administration, or related field preferred
• Minimum of two years of medical billing experience, preferably within Medi-Cal, managed care, behavioral health, or community-based services
• Knowledge of CalAIM, Enhanced Care Management (ECM), Community Supports (CS), and Medi-Cal billing practices preferred
• Experience with electronic medical record (EMR/EHR) and billing software systems
• Understanding of HIPAA regulations, healthcare documentation standards, and claims processing workflows
• Strong attention to detail, organizational skills, and ability to manage multiple priorities
• Excellent communication and problem-solving abilities

Key Responsibilities

Billing & Claims Management

• Submit invoices and claims to Managed Care Plans (MCPs) for ECM and Community Supports services rendered to authorized members
• Prepare and submit clean claims electronically or by paper in accordance with payer guidelines, DHCS standards, and MCP requirements
• Submit claims utilizing national standard specifications, billing codes, and code sets established by DHCS for ECM and Community Supports services
• Ensure maximum reimbursement through accurate billing, coding, and documentation review
• Review claims for accuracy, completeness, and compliance prior to submission
• Monitor claim status and assigned billing queues daily to support timely payment processing
• Manage claims follow-up, denial management, corrections, appeals, and resubmissions as needed
• Process and reconcile payer responses, payment postings, and billing reports

Authorization & Eligibility Oversight

• Verify member eligibility with assigned MCPs prior to billing and throughout service enrollment periods
• Monitor and maintain ECM and Community Supports authorizations, referrals, and service approvals
• Ensure services billed are authorized, medically appropriate, and documented in accordance with DHCS and MCP requirements
• Track authorization expiration dates and coordinate reauthorization needs with program staff

Documentation & Compliance

• Maintain accurate and up-to-date data in electronic medical record (EMR/EHR) systems and billing platforms
• Ensure documentation supports billed services and complies with ECM and Community Supports standards, including encounter documentation requirements
• Maintain strict confidentiality of protected health information in compliance with HIPAA and organizational policies
• Support compliance with consent, authorization, and data-sharing requirements related to CalAIM services
• Assist with audits, monitoring activities, and reporting requests related to billing and claims processing

Coordination & Communication

• Coordinate with care managers, housing support staff, supervisors, and external partners to obtain necessary documentation and service information
• Communicate with MCP representatives regarding claims, authorizations, billing inquiries, and service requirements
• Assist staff in resolving documentation deficiencies impacting billing or reimbursement
• Participate in interdisciplinary meetings as needed to support program operations and billing integrity

Training & Quality Improvement

• Attend required trainings and maintain current knowledge of CalAIM, ECM, Community Supports, DHCS, and MCP billing requirements
• Stay informed on policy, coding, and compliance updates impacting billing practices
• Contribute to process improvement efforts to enhance billing accuracy, compliance, and reimbursement outcomes