Senior Claims Specialist

Illumination Health + Home • Santa Ana, CA

1d • $30 - $32 • Hybrid

About The Position

The CalAIM Senior Claims Specialist is responsible for ensuring accurate and compliant claim submission, payment posting, denial resolution, and billing follow-up for CalAIM contracted services. This position plays a critical role in supporting the organization’s revenue cycle by ensuring claims meet payer requirements, coordinating with internal departments, and maintaining compliance with state and contractual billing standards.

Requirements

• 1–3 years of experience in medical billing, preferably in behavioral health, Medi-Cal, or CalAIM programs.
• Knowledge of ICD-10, CPT/HCPCS coding, and standard billing practices.
• Experience reviewing EOBs, RAs, and payer adjudication messages.
• Familiarity with authorization management and eligibility verification processes.
• Strong attention to detail and ability to work with a high level of accuracy.
• Proficiency with billing software, EHR systems (e.g., Kipu), and payer provider portals.
• Maintain clear, timely, and professional communication with colleagues, supervisors, and external partners to ensure smooth coordination, accurate information sharing, and efficient workflow.
• Must be motivated to work independently and in a group setting.
• Effective communication with providers, departments, and payers.
• Ability to prioritize tasks and meet timelines.
• Be able to meet targets and work under pressure with a high volume of claims
• Consistent adherence to regulatory and payer guidelines.
• Proactive approach to resolving billing and documentation challenges.

Nice To Haves

• Experience with CalAIM or Medi-Cal Managed Care billing.
• Knowledge of DHCS policies, CalAIM documentation requirements, and state billing mandates.
• Understanding revenue cycle management and claim lifecycle workflows.
• Prior experience with appeals, PDRs, or complex denial management.

Responsibilities

• Ensure all claims meet CalAIM, Medi-Cal, payer, and internal program requirements prior to submission.
• Review, validate, and correct rejected, denied, or pending claims; complete all follow-up within required timelines.
• Verify service authorizations via provider portals, authorization letters, or Kipu documentation.
• Conduct comprehensive pre-submission audits to ensure clean claims, including validation of CPT/HCPCS codes, ICD-10 diagnoses, modifiers, and encounter data.
• Manage claims on hold: identify missing documentation, coordinate with departments, and bill once cleared.
• Create, modify, or adjust claims as needed based on clinical documentation and payer requirements.
• Review client records to extract all necessary billing information, including ICD-10 diagnosis codes, CPT/HCPCS codes, and service details.
• Ensure billing accuracy in alignment with CalAIM program rules, service definitions, and documentation standards.
• Verify client eligibility via payer or DHCS portals prior to claim submission.
• Maintain accurate documentation, audit trails, and data integrity for all billing activities.
• Review and interpret Explanations of Benefits (EOBs), Remittance Advices (RAs), and adjudication messages.
• Initiate, track, and respond to Provider Dispute Resolutions (PDRs) or appeals; escalate complex denials as needed.
• Perform timely and accurate follow-up to resolve claim issues, discrepancies, and payment variances.
• Accurately post payments, adjustments, and reversals to claims in the billing system.
• Complete claim close-out processes and reconcile posted amounts with payer remittances.
• Identify underpayments or payment errors and escalate for correction.
• Maintain strict compliance with CalAIM, DHCS, Medi-Cal, HIPAA, and payer-specific billing guidelines.
• Participate in internal audits, QA reviews, and data integrity checks.
• Assist in producing billing reports such as aging, denial trends, or productivity metrics.
• Monitor and support improvement of revenue cycle KPIs, including clean-claim rate, denial rate, and aging.
• Collaborate with Clinical, Admissions, UR, QA, and Accounting teams to resolve billing issues or documentation discrepancies.
• Communicate recurring issues or process gaps to supervisors to support ongoing workflow improvement.
• Assist supervisors with billing-related projects, including system updates, workflow enhancements, or compliance implementations.
• Support the rollout of new CalAIM or payer requirements, including documentation or coding updates.
• Participate in staff training or cross-training as needed.
• Perform other billing duties as assigned.

Benefits

• Medical Insurance funded up to 91% by Illumination Health + Home (Kaiser and Blue Shield), depending on the plan
• Dental and Vision Insurance
• Life, AD&D and LTD Insurance funded 100% by Illumination Health + Home
• Employee Assistance Program
• Professional Development Reimbursement
• 401K with Company Matching
• 10 days vacation PTO/year
• 6 days of sick pay/year
• Potential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed
• Number of Employees: 251-500 employees