ECM - Billing Specialist

Description

CalAIM Enhanced Care Management (ECM) is a patient-centered program under California’s CalAIM (California Advancing and Innovating Medi-Cal) initiative, designed to provide comprehensive, whole-person care to Medi-Cal beneficiaries with complex health and social needs. The ECM program focuses on high-risk population, such as individuals with multiple chronic conditions, serious mental health and substance used needs and those experiencing homelessness and Justice Involved (JI) by offering intensive coordinated care management and other services. Though a team-based approach, ECM program staff work closely with members, healthcare providers, and community organizations to address the medical, behavioral, and social determinants of health (SDOH) connecting members to vital resources such as housing support, mental health services, and social services. The goal of the ECM Program is to improve health outcomes, reduce health disparities and promote better health and stability for vulnerable population in our community. 

Under the supervision and guidance of the ECM Program Director, the ECM Billing Specialist is responsible for supporting the billing, data management, and reporting processes specifically for CalAIM and ECM initiatives. This role ensures accurate tracking, billing and reporting of services rendered under the BVHPF ECM Program with a focus on compliance and program integrity. The Billing Specialist will have a strong have a strong background in healthcare billing, an understanding of Medi-Cal regulations, and the ability to analyze and validate complex data sets. The ECM Billing Specialist is essential for ensuring that the ECM Program services are billed correctly, claims are processed efficiently, and data is leveraged for strategic decision-making. 

Requirements

Billing & Claims Management: Prepare, review and submit CalAim-ECM billing claims, ensuring compliance with Medi-Cal requirements, Managed Care Plans (MCP), and ECM program guidelines. Verify and reconcile data related to member services, ensuring all documentation is complete and accurate prior to claim submission. Identify, research, and resolve billing discrepancies, working closely with the ECM program team and contracted MCPs. Monitor claims status, track denials, and follow-up to ensure timely payments and resolution of billing issues. 

Data Coordination & Reporting: Maintain comprehensive records of ECM services, tracking utilization, service delivery and outcomes. Extract, validate, and analyze data from multiple sources to generate detailed reports for the ECM Director, MCPs, internal and external stakeholders. Assist in developing monthly, quarterly and annual reports for the ECM program performance and compliance reviews. 

Compliance & Program Integrity: Ensure billing practices adhere to all applicable state and federal regulations, including Medi-Cal, CalAIM and MCPs requirements. Participate in audits and compliance reviews, preparing necessary documentation and responding to inquiries from auditors. Maintain and stay an up-to-date understanding of CalAIM-ECM and MCPs requirements, including changes in reimbursement policies and procedures. Provide data insights to support strategic planning and program evaluation by ensuring that appropriate billing and diagnosis codes (e.g. ICD-10, CPT, HCPCS) are used for the services provided, adhering to ECM-specific guidelines and regulations. 

Collaboration & Communication: Act as a liaison between the billing, ECM and Compliance team to ensure accurate data sharing and alignment. Collaborate with ECM Director to identify process improvements and implement best practices for data management and billing workflows. Serve as the point of contact for billing-related inquiries, providing support to ECM program staff, providers, MCPs and internal and external stakeholders.

Program Development: Models the highest ethical standards in billing management and building relationships with co-workers, supervisors, members, providers, and colleagues in the community while maintaining a positive holistic approach. Assist the ECM team in providing clear understanding of billing requirements, corrections, and denials. Engage and track in Continuous Quality Improvement (CQI) initiatives on billing metrics by identifying gaps to address, develop and test new practices to improve the ECM billing outcomes. Ensures billing is accurate, helpful and compliant with regulatory requirements of BVHPF and MCPs. Contribute to the development and enhancement of the ECM services offering input on program improvements, workflow optimizations, and best practices. Participate in all ECM team meetings and perform other duties as assigned by the ECM Director. 

Qualifications:

Education: Bachelor's degree in nursing, Social Work, Public Health, or a related field.

 (Master’s degree preferred.)

Experience: Minimum 2-3 years in billing, coding, with understanding, high-need care coordination and management, including those with mental health conditions, homelessness, and substance use disorders, with at least 1-2 years lived experience, including experience working with LGBTQI , young people and their families, caregivers, child welfare, foster system, older adults and individuals with chronic illness communities. 

Licensure/Certification: Possession of a valid California Driver’s License with a driving record that meets agency standards. Auto Insurance and access to a reliable vehicle.  

Leadership Skills: Strong communication and interpersonal skills, with problem-solving skills. Ability to work independently and as part of a team. 

Knowledge: In-depth knowledge and understanding of high-need care coordination, chronic disease management, behavioral health, social determinants of health (SDOH), community resources, healthcare services and billing codes. 

Technical Skills: Proficiency in case management software such as: electronic health records (EHR), Avatar, Epic and data reporting tools, including knowledge of Microsoft Office, Internet browsers, etc. 

Physical & Additional Requirements:

Regular and reliable job attendance.

Effective verbal and written communication skills.

Exhibit respect and understanding of others to maintain professional relationships.

Independent judgement in evaluation options to make sound decisions.

Ability to work effectively in an open office environment surrounded by moderate noise and distractions.

Frequently required to sit; occasionally walk and stand; travel from the building to other sites.

Specific vision abilities required by this job include close vision, distance vision, depth perception, and the ability to adjust focus.

The employee must be able to meet case notes deadlines with time constraints. 

Able to meet required state, federal, local and BVHP standards.

Live Scan fingerprinting and TB clearance as well as any other medical vaccinations may be required.

At least two COVID-19 vaccinations (preferred).

As part of our commitment to maintaining a secure environment, all candidates selected for this position will be subject to a comprehensive background check clearance. This clearance is a standard part of our employment process and is conducted in accordance with applicable laws and regulations.

Provide proof of California Driver’s Licenses, proof of insurance and current registration with a clean driving record.