Medi-Cal Billing & Follow-Up Specialist

The Medi-Cal Billing and Follow-up Specialist is responsible for managing all of the following for both Hospital and Professional accounts receivable: billing, AR follow-up, short-pay analysis, denials and refunds. The Specialist will manage all aspects of the accounts receivable in accordance with the specific payer guidelines, policies, procedures, and compliance regulations for Medi-Cal and Managed Medi-Cal. The Specialist will ensure timely resolution of accounts receivable by researching accounts, refiling or appealing claims, submitting additional medical documentation, and tracking account status by monitoring and analyzing unresolved balances, to ensure continuity of cash flow. Coordinate payer denial and appeal follow-up activities to ensure timely processing of all payer denials. Communicate global payer issues to the payer relations team. Communicate and coordinate with various individuals/distributions and assist with monitoring of the day-to-day activities related to denials, appeals, and follow-up. Review all denied accounts for categorization, level of appeal, special requirements for initiating appeals. Maintain expert level knowledge of federal, state, and third-party claims processing. Support projects and initiatives of the revenue cycle teams, including conducting research for payer criteria, and preparing documents. Organize all data and activity in a retrievable way to ensure timely follow-up on appeals to their party payers. Assist with the coordination of denial and review activities and materials for committee meetings, including analysis, reports, etc. Analyze Explanation of Benefits to ensure claims have processed correctly. Appeal all underpaid claims Analyze and identify root causes of claim edits. Escalate trends to management Monitor and work all claim edits to ensure they are fully resolved in a timely manner. Ensure accurate processing of claims in a manner that is consistent with industry standards, regulations, and SHC policies and procedures. Work rejected and denied claims. Use problem solving skills to determine root cause and escalate trends to management Prioritize activities to alleviate untimely filing. Research, verify, and take appropriate actions as it relates to all pre-billing adjustments. Consistently seek improvement in processes and procedures for all billing and reimbursement functions, to include problems with workflow, and billing issues. Escalate possible process improvement initiatives to management Analyze and resolve all credit balances in accordance with payer guidelines. Build and maintain relationships with payer representatives. Crosstrain in multiple areas, as well as perform all other duties as assigned.