POSITION SUMMARY:

This position is responsible for preparing, submitting, and reconciling billing data for services provided under CalAIM, including DMC-ODS, Enhanced Care Management (ECM), and Community Supports. This position ensures claims are submitted accurately and timely directly to insurance carriers and Medi-Cal Managed Care Plans (MCPs) in accordance with all DHCS, payer, and organizational guidelines.  The specialist works closely with fiscal, clinical, and data teams to ensure service documentation meets billing standards, resolve denials, and maintain the integrity of client and program data across systems.

Essential Job Functions include those listed below.

ESSENTIAL JOB FUNCTIONS:

Prepare, submit and track CalAIM claims directly to Medi-Cal Managed Care Plans and insurance carriers. Verify client eligibility, authorizations, and service coverage using payer portals and eligibility systems. Review clinical documentation to ensure completeness, accuracy, and compliance before billing. Apply correct procedure codes (CPT/HCPCS), modifiers, and units in line with CalAIM billing. Reconcile payments and denials; research and correct claim errors or rejections in coordination with fiscal and program staff. Maintain and update billing records, logs, and spreadsheets to ensure data accuracy and audit readiness. Generate billing, payment, and denial reports for management review. Monitor claim timeliness, submission deadlines, and reimbursement trends. Communicate with Managed Care Plan representatives as needed to resolve claim or authorization issues. Support internal and external audits, ensuring documentation and claims meet DHCS and payer compliance standards. Maintain strict confidentiality of all client and financial data in accordance with HIPAA. Must Embrace and embody the mission, vision, guiding principles, clinical vision, and goals of WestCare Foundation; and Perform all other duties as assigned.