Billing Auditor

Pacific Health Group•Carlsbad, CA

6h•$25 - $27

About The Position

Pacific Health Group (PHG) is a California-based integrated care organization delivering Enhanced Care Management (ECM), Community Supports (CS), and Behavioral Health (BH) services under the CalAIM framework. We serve Medi-Cal members across multiple counties through contracts with managed care plans and county behavioral health systems. Our mission is simple: deliver whole-person care that meets people where they are—and make sure the systems behind that care run as effectively as the care itself. THE ROLE We’re looking for a detail-driven Billing Auditor who will own the critical space between service delivery and revenue collection. You’ll make sure that every claim we submit gets paid—correctly and completely. You’ll audit our claims, dig into EOBs and remittance advices, chase down underpayments, and build the systems that keep revenue from slipping through the cracks. This is not a passive paper-pushing role. You’ll be the person who catches what others miss and turns findings into action.

Requirements

3+ years in medical billing, claims auditing, or revenue cycle management in healthcare.
Hands-on experience auditing EOBs, reconciling payments, and managing denials and appeals.
Working knowledge of HCPCS, CPT, and ICD-10 coding.
Proficiency with EHR/billing systems and strong Excel or Sheets skills for data analysis.
Sharp analytical instincts and relentless attention to detail.
Bachelor’s degree in healthcare administration, HIM, business, accounting, or equivalent experience.

Nice To Haves

Experience with Medi-Cal managed care, CalAIM (ECM/CS), or behavioral health billing.
Familiarity with PEPM/capitated payment models.
CPC, CCS, or equivalent coding certification.
Knowledge of 837/835 electronic transaction standards.
Background in community health, FQHCs, or integrated care settings.

Responsibilities

Reconcile every submitted claim against EOBs, 835 remittance advices, and payment records to verify we received full and accurate reimbursement.
Audit PEPM payments against enrollment rosters, service logs, and LOA rate schedules across all MCP contracts.
Identify underpayments, denials, zero-pays, and systematic payment discrepancies—then drive resolution.
Prepare and file appeals for denied or underpaid claims with complete supporting documentation.
Cross-reference clinical documentation, care plans, and EHR records against claims to find unbilled and under-billed services.
Verify correct coding across HCPCS, CPT, and ICD-10—including CalAIM-specific ECM codes (G9007, G9008, G9012), CS codes and BH/SMHS codes.
Build and maintain audit dashboards tracking denial rates, days in A/R, collection rates, and payer-level variances.
Produce monthly revenue reconciliation reports for leadership with actionable findings.
Recommend and implement process improvements that prevent revenue leakage at the source.