PRE-BILLING QUALITY SPECIALIST

Apis Services Inc•Philadelphia, PA

22d

About The Position

The Pre-Billing Quality Specialist ensures that all billing across IDD (Intellectual and Developmental Disabilities) and BHH (Behavioral Health Home) programs meets payer and regulatory requirements prior to claim submission. This role verifies that all services are fully supported by accurate documentation, appropriate authorizations, and correct utilization. The Specialist proactively identifies and resolves issues that may delay or prevent billing, working closely with Program teams and Revenue Cycle Management (RCM) to ensure timely and accurate reimbursement.

Requirements

High School Diploma or GED required; Associate’s degree preferred
Valid Driver's License minimum of three years.
2+ years of experience in: Behavioral Health, IDD, or Medicaid-funded billing
Strong knowledge of: Medicaid billing processes Denials management EHR systems and reporting tools
Advanced proficiency in Microsoft Excel, including working with large datasets
Experience navigating multiple EHR systems
Knowledge of billing software and reporting tools
Strong attention to detail and accuracy
Excellent organizational and time-management skills
Analytical and problem-solving abilities
Effective written and verbal communication
Ability to manage multiple priorities and meet deadlines
Ability to work independently and collaboratively
Solution-oriented mindset with a focus on continuous improvement
Must comply with: HIPAA regulations OSHA and safety standards Organizational policies and procedures

Responsibilities

Review service documentation to ensure compliance with payer-specific billing requirements
Verify completion of all pre-billing steps, including: Documentation completion Service entry accuracy Authorization validation Unit totals
Confirm required elements such as: Signatures Timelines Service codes and modifiers Utilization limits
Identify and coordinate correction of missing or inaccurate documentation
Validate service data, authorizations, and payer information prior to claim submission
Identify and resolve pre-billing issues such as data discrepancies and authorization conflicts
Collaborate with Program leadership and RCM to address: Denials Returned claims
Track denial trends and support implementation of corrective actions
Track service utilization to prevent exceeding authorized limits
Monitor authorizations for accuracy in: Units Service codes Effective dates
Notify program staff of discrepancies or upcoming expirations
Generate and analyze reports from systems such as: Avatar SetWorks Therap BHL
Produce KPI and pre-billing reports to identify trends and outstanding issues
Validate billing-related data across multiple EHR platforms
Ensure documentation supports all billed services
Train program staff on billing requirements, documentation standards, and system processes
Communicate findings and issues clearly to program teams and RCM
Recommend workflow improvements to enhance accuracy and reduce denials
Assist in evaluating and improving workflows related to: Pre-billing and billing processes Consumer change forms Opening/closing service locations
Perform additional duties as assigned by leadership