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Salary: $20.00-$23.00
POSITION SUMMARY
Reporting to the Controller, the DMH Billing Specialist is responsible for timely processing and submission of claims using the Welligent electronic health record system (EHRS) and hard copy documents, assuring compliance with Medi-Cal, Los Angeles County Department of Mental Health contract (LACDMH), and Other Health Coverage (OHC) Carrier rules.
ESSENTIAL DUTIES AND RESPONSIBILITIES
In addition to all components of the above position summary the following ?Essential Duties and Responsibilities? are essential to successful performance in this position
- Processes and submits claims to the correct payors in sequence including weekly claims ?gathering' into claims cycles using the Welligent EHRS, for submission to Other Health Coverage (OHC) Carriers such as Kaiser and Anthem Blue Cross; follows up as needed to ensure claims do not age out, and adhere to the ?90 Day Rule? for submission to Medi-Cal.
- Performs data entry and administration of provider data into the systems required for claiming their services; verifies and administers client eligibility data in support of claims; processes and submits claims and claim explanation of benefit (EOB) response files using Welligent and paper-based HCFA1500 forms in a timely manner; ensures claims compliance with Medi-Cal, DMH, and OHC Carrier rules.
- Maintains detailed records on submitted claims, claim status, and all status issues that may result in non-payment; reports claim issues to a supervisor with recommendations on follow up.
- Monitors and analyzes claims cycles for any issues, errors, and rule violations before submission; resolve issues and/or reports problems to the supervisor.
- Monitors electronic and paper claims responses to ensure accurate/complete files and data entry of the EOB information into Welligent; tracks and reconciles the claims submitted to the responses received.
- Administers provider data including manual data entry to maintain accurate records in the DMH IBHIS Provider Registration & Maintenance (PRM) system, as well as the EHRS; manages the DMH application access process to enable providers to bill for their services, using RSA security token access to the DMH system.
- Collaborates with members of DMH Billing, Quality Assurance, Charts, and Records and Finance teams to ensure communication on issues relating to OHC claims, eligibility, and unbilled services.
- Gathers data and prepares special projects and reports relating to billing as requested.
- Maintains confidentiality regarding the accounting and operations of the Agency.
- May represent Phoenix House at payer billing-related meetings as assigned.
- Processes and submits claims to the correct payors in sequence, including weekly claims ?gathering' into claims cycles using the Welligent EHRS, for electronic claims submission (EDI) to the LACDMH and Medi-Cal payers; submits EDI claims to LACDMH in a timely manner such that claims do not age out; maintains detailed records on submitted claims, claim status and all issues that may result in non-payment.
- Monitors and analyzes claims cycles for any issues, errors, and rule violations before submission; reports claim issues to a supervisor with recommendations for necessary follow up.
- Monitors/processes claims responses, including monitoring for response files in the DMH secure file transfer web site, such as TA1, 999, 277, 837, and 835 files; downloading and processing these files in the Welligent EHRS; reviews 835 response files for accuracy and issues, as well as tracking and reconciling submitted claims to the responses received.
- Verifies client's Medi-Cal eligibility regularly, using an electronic batch method to create and submit files for verification; updates client records accordingly.
- Leads research to identify the root cause of issues and determines/implements solutions, preventing submission to the payor or causing payor denials of claims.
- Processes/verifies client Medi-Cal eligibility verification via electronic batches submitted to the state system, including making manual data entry modifications to client pay sources in the EHRS and record updates in the DMH IBHIS system via electronic Client Web Services (CWS) commands; forwards eligibility change communication to appropriate clinical staff and follow up.
- Researches and resolves the claim with issues preventing the claims from being submitted to payors or that resulted in denials, including billing related violations in the Welligent EHRS; researches state Medi-Cal and local LACDMH claim denials; implement the fix in Welligent or escalates and follows-up with others as necessary.
- Researches and resolves any local LACDMH file rejections that result from technical transaction format and other issues.
- Runs claim related reports, reviews, and follows-up on apparent issues in these reports; researches resolves or escalates to others as necessary.
- Creates, runs, and maintains designated annual and semi-annual corporate reports for program staff (e.g., RBS and Wrap Around program reports); utilizes Welligent Unbilled report to create the monthly reconciliation data for Summit Meetings that reflects tracking actuals to funding caps.
- Collaborates/communicates with members of DMH Billing, Quality Assurance, Charts and Records, and Finance teams on issues relating to OHC claims, eligibility, and unbilled services.
- Gathers data and prepares special projects and reports relating to LACDMH billing.
- Maintains confidentiality regarding the accounting and operations of the Agency.
- Attends all required staff training sessions in accordance with Phoenix House and state licensing requirements, completes all training on time
- Attends and participates in program and all staff meetings
- Adheres to and promotes the Phoenix House Mission, Vision, and Values while acting as a role model for others
- Other duties as assigned
SUPERVISORY RESPONSIBILITIES
The incumbent in this position has no supervisory responsibilities
EDUCATION/EXPERIENCE/CREDENTIALS
- High Diploma or GED; Associate degree in Accounting or Business required
- One (1) to three (3) years billing experience preferred
- Prior experience in non-profit preferred
- Must maintain a valid California Drivers' License, have proof of automobile insurance and maintain a safe driving record based on Phoenix House policy
KNOWLEDGE, SKILLS, AND ABILITIES
To perform this position successfully, you must be able to perform each essential duty and responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities. The requirements listed below are representative of the knowledge, skill, and/or ability required
- Demonstrated commitment and adherence to Phoenix House Mission, Vision, and Values: I CARE For? Integrity, Collaboration Appreciation, Respect, Excellence, and Forward-Thinking
- Proficiency in MS Office systems
- Ability to utilize an electronic healthcare record
- Using mathematics to solve problems
- ability to choose the right mathematical methods or formulas to solve a problem
- ability to add, subtract, multiply, or divide quickly and correctly
- Establish and maintain effective working relationships with others
- Communicate effectively with others both orally and in writing
- Ability to work effectively in a fast-paced changing environment
- Ability to model positive behavior and demeanor
- Excellent time management and organizational skills
- Ability to be flexible; problem solver, self-directed; customer service-oriented, and collaborative
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