CalAIM Medical Billing Specialist

Friends Outside•Stockton, CA

About The Position

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.

Requirements

High school diploma or equivalent required
Minimum of two years of medical billing experience, preferably within Medi-Cal, managed care, behavioral health, or community-based services
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

Nice To Haves

Associate’s degree in Medical Billing and Coding, Healthcare Administration, Business Administration, or related field preferred
Knowledge of CalAIM, Enhanced Care Management (ECM), Community Supports (CS), and Medi-Cal billing practices preferred

Responsibilities

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
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
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
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
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