Medical Billing Operations and Escalations Specialist - Codemax Medical Billing

Job Title: Medical Billing Operations and Escalations Specialist

Location: Van Nuys, CA

EMPLOYMENT STATUS: Full-Time 

CLASSIFICATION: Exempt 

Position Summary:

The Operations and Escalations Specialist is a highly motivated and detail-oriented individual. They possess a strong understanding of medical billing procedures, coding, insurance claims, and excellent customer service skills. This position will be responsible for ensuring accurate and efficient billing operations as well as working with customers/facilities to both proactively and reactively address billing issues. Below are the job duties and responsibilities outlined, however, the job duties are not limited to the items listed.

 Duties/Responsibilities: 

1. Oversees the management and organization of SA and MH medical records

2. Familiarity with ASAM, LOCUS, and MCG criteria to review and assess the appropriateness of treatments and recommendations. 

3. Ensures the confidentiality of patient information in compliance with HIPAA and other relevant guidelines. 

4. Trains and guides clinical staff on proper record-keeping for all of the Departments (VOB,UR, BILLING etc...)

5. Using their extensive knowledge and experience with Substance Abuse billing science and technology, resolves discrepancies or issues in patient records and makes corrections exercising sound independent judgment and making impactful decisions grounded in lessons learned/education gained. 

6. Monitors and ensures staff compliance with the latest SA and MH regulations 

7. Generates and reviews reports related to patient care, interventions, and compliance 

8. Generates and reviews operational metrics understanding and acting upon trends, bottlenecks and anomalies

9. Anticipates adverse customer impacts and proactively communicates with Customers as well as driving and communicating resolutions

10. As a point of escalations, follows up on unpaid claims and manages denials by conducting investigations and assisting with filing appeals

11. Participates in management meetings, offering insights, and updates related to SA and MH Claims, billing, posting, utilization review, vob and medical records

12. Documents medical billing procedures and trains staff as necessary

13. Resolves patient and customer inquiries and complaints related to medical billing 

14. Provides training and guidance to peers and operational staff as required

15. Stays updated with the latest trends, research, and regulations in SA and BH care and record-keeping 

16. All other duties as assigned 

Required Skills/Abilities: 

1. Strong leadership and managerial abilities

2. Excellent organizational skills and attention to detail 

3. Superior problem-solving abilities and analytical thinking 

4. Outstanding written and verbal communication skills 

5. Proficiency in data management, data entry, and basic office software applications 

6. Strong issue resolution and customer/patient de-escalation skills

7. The successful candidate will possess a deep understanding of SA and BH medical records, be familiar with ASAM, LOCUS, MCG criteria, and exhibit management prowess.

8. The specialist will ensure efficient and compliant operations related to SA and BH medical records 

Education and Experience: 

1. Bachelor’s or Master’s degree in a clinical field such as psychology, social work, or a related field. Advanced degrees preferred. 

2. Certification or specialized training in ASAM, LOCUS, MCG, or a combination thereof. 

3. Minimum of three (3) years of clinical experience with an emphasis in SA and MH. 

4. Management experience is a plus. 

5. Knowledge and proficiency in electronic health records (EHR) related to SA and MH. 

6. In-depth understanding of clinical assessment tools and criteria such as ASAM, LOCUS, and MCG. 

7. Has work within and is comfortable working within a matrixed structure.

Physical Requirements and Work Environment: 

The physical demands described here are representative of those that must be met by a teammate to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

1. While performing the duties of this job, the employee is regularly required to stand, sit; talk, hear, and use hands and fingers to operate a computer, reach, stoop, kneel.  

2. Light to moderate lifting of up to 15 pounds is required. 

3. Prolonged periods sitting at a desk and working on a computer. 

The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.