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Illumination Health + Home · 21 hours ago

Senior Claims Specialist

Santa Ana, CA

Full-time

Hybrid

Mid, Senior Level

$30/hr - $32/hr

1+ years exp

Illumination Health + Home is a growing non-profit organization dedicated to disrupting the cycle of homelessness. 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.

Non Profit

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

Qualification

ICD-10 codingCPT/HCPCS codingMedical billing experienceEHR systems proficiencyDenial managementAttention to detailCommunication skillsTeam collaboration