Shriners Children’s is an organization that respects, supports, and values each other. We are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families.

All employees are eligible for medical, dental and vision coverage on their first day! In addition, upon hire all employees are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. Employees in a full-time or part-time status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans. Additional benefits available to full-time and part-time employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more! Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law.

The Medi-Cal Billing and Follow-up Specialist is responsible for managing all of the following for both Hospital and Professional accounts receivable: billing, AR follow-up, short-pay analysis, denials and refunds. The Specialist will manage all aspects of the accounts receivable in accordance with the specific payer guidelines, policies, procedures, and compliance regulations for Medi-Cal and Managed Medi-Cal. The Specialist will ensure timely resolution of accounts receivable by researching accounts, refiling or appealing claims, submitting additional medical documentation, and tracking account status by monitoring and analyzing unresolved balances, to ensure continuity of cash flow.

• Coordinate payer denial and appeal follow-up activities to ensure timely processing of all payer denials.
• Communicate global payer issues to the payer relations team.
• Communicate and coordinate with various individuals/distributions and assist with monitoring of the day-to-day activities related to denials, appeals, and follow-up.
• Review all denied accounts for categorization, level of appeal, special requirements for initiating appeals.
• Maintain expert level knowledge of federal, state, and third-party claims processing.
• Support projects and initiatives of the revenue cycle teams, including conducting research for payer criteria, and preparing documents.
• Organize all data and activity in a retrievable way to ensure timely follow-up on appeals to their party payers. Assist with the coordination of denial and review activities and materials for committee meetings, including analysis, reports, etc.
• Analyze Explanation of Benefits to ensure claims have processed correctly.
  
  • Appeal all underpaid claims
• Analyze and identify root causes of claim edits.
  • Escalate trends to management
• Monitor and work all claim edits to ensure they are fully resolved in a timely manner.
• Ensure accurate processing of claims in a manner that is consistent with industry standards, regulations, and SHC policies and procedures.
• Work rejected and denied claims.
  
  • Use problem solving skills to determine root cause and escalate trends to management
• Prioritize activities to alleviate untimely filing.
• Research, verify, and take appropriate actions as it relates to all pre-billing adjustments.
• Consistently seek improvement in processes and procedures for all billing and reimbursement functions, to include problems with workflow, and billing issues.
  
  • Escalate possible process improvement initiatives to management
• Analyze and resolve all credit balances in accordance with payer guidelines.
• Build and maintain relationships with payer representatives.
• Crosstrain in multiple areas, as well as perform all other duties as assigned.

This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned.

Minimum:

• 5+ yrs of experience in medical billing including EDI Transaction sets, UB05 and 1500 claim forms
• 3+ yrs of experience in insurance claims processing and follow-up
• Expert knowledge in federal, state and third-party claims’ processing practices
• Expertise regarding CCI edits, HCPCS, ICD-10, and Revenue Codes
• Experience navigating Medi-Cal (California Medicaid Healthecare Program) portals for billing and follow-up
• High School Diploma/GED

Preferred:

• Epic experience