Role: Medical Billing Consultant
Remote
Contract to Hire/FTE
Position Summary: We are seeking a seasoned Medical Billing Consultant with a strong background in medical billing to optimize Enhanced Care Management (ECM) billing practices. The ideal candidate will have real-world experience working with health plans and a proven track record of successful and compliant medical billing practices. This role will involve enhancing revenue cycles by reducing claim denials and ensuring compliance with ECM-specific regulatory requirements.
Key Responsibilities:
- ECM Billing Optimization:
- Lead efforts in ECM billing optimization, including accurate coding, claim submission, and reimbursement processes.
- Ensure proper utilization of HCPCS, CPT, ICD-10, and ECM-specific modifiers, as well as Social Determinants of Health Z-codes.
- Collaborate with case management teams to secure accurate documentation and verify client eligibility.
- Claims and Denial Management:
- Oversee ECM claim submissions and follow-ups to provide recommendations on how to maximize reimbursements.
- Analyze the management of existing denials and appeals processes, identify trends, help resolve issues, and develop strategies to minimize future denials.
- Review the explanation of benefits (EOBs) reconciliation process to ensure accurate payments.
- Compliance and Regulatory Adherence:
- Maintain up-to-date knowledge of state, federal, and payer-specific ECM regulations, including Medi-Cal requirements.
- Ensure ECM billing practices align with regulatory standards and payer guidelines.
- Communicate with health plans to clarify billing requirements and help resolve complex issues.
Qualifications:
- Education & Certification:
- High school diploma or GED required; Associate degree or certification in medical billing/coding preferred.
- CPC (Certified Professional Coder), CPB (Certified Professional Biller), or equivalent certification is a plus.
- Experience:
- Minimum of 2 years in medical billing, particularly with ECM and Social Determinants of Health services.
- CalAIM ECM billing experience is desired, it is not mandatory.
- Prior experience with health plans and government payers, especially Medi-Cal, is essential.
- Demonstrated success in reducing denials and optimizing billing practices for ECM services.
- Technical Skills & Competencies:
- Proficiency in medical billing software and familiarity with payer portals.
- Strong analytical, problem-solving, and communication skills.
- Ability to work independently and collaboratively in a mission-driven environment.
