RCM Billing Specialist in Pleasanton, California at Paradigm Oral Surgery

ROLE OVERVIEW

The Pre-Authorization & Billing Specialist plays a dual role in the Revenue Cycle Management (RCM) department by ensuring timely and accurate pre-authorizations for procedures and submitting clean claims for reimbursement. This role serves as a key link between clinical operations, insurance payers, and the billing team to help maximize revenue, reduce denials, and maintain compliance.

KEY RESPONSIBILITIES

• Submit timely and complete pre-authorization requests to insurance payers with supporting documentation (clinical notes, X-rays, narratives).
• Track authorization statuses, follow up on pending requests, and escalate delays as needed.
• Maintain detailed logs of approval/denial statuses, including authorization numbers and expiration dates.
• Communicate authorization updates to clinical and front office teams in a timely manner.
• Stay current with payer-specific pre-auth requirements and documentation rules.
• Submit accurate, compliant claims using proper CDT, CPT, and ICD-10 coding.
• Resolve claim edits and rejections in clearinghouse or EHR system.
• Coordinate with insurance verification and AR teams to ensure all claim data is correct.
• Ensure claims are submitted within payer timely filing deadlines.
• Document claim actions in patient accounts for visibility and continuity.
• Partner with pre-authorization and AR follow-up teams to avoid billing delays.
• Escalate denials, trends, or payer policy updates to leadership.
• Maintain compliance with HIPAA, payer regulations, and company SOPs.
• Participate in training, audits, and process improvement initiatives as needed.

Essential Qualifications

Prior experience in dental office revenue cycle functions, with expertise in:

• Scheduling & Registration – Understanding patient flow and eligibility verification.
• Insurance Verification – Confirming coverage, benefits, and policy limitations.
• Fee Schedules & Charging/Coding – Ensuring accurate claim submission using CDT, CPT, and ICD-10 codes.
• Claim Submission & Follow-Up – Knowledge of clean claim processing, payer-specific requirements, and handling rejections/denials.

Strong knowledge of reimbursement & compliance processes for:

• Medicare, Medicaid, PPO, HMO, and Fee-for-Service (FFS) plans
• Payer guidelines, coordination of benefits (COB), and timely filing limits
• Insurance dispute resolution and appeal submission best practices

Proficiency in dental billing software & industry tools:

• Practice Management Systems (PMS): CareStack, WinOMS, OMSVision, Dentrix, Eaglesoft, etc.
• Insurance Portals & Clearinghouses: Working with Navinet, Availity, Change Healthcare, and payer-specific platforms

Microsoft Office Suite:

• Strong computer literacy.
• Strong interpersonal and organizational skills to work effectively within a team and independently.
• Excellent oral and written communication skills, particularly in handling payer escalations and patient billing inquiries.
• Demonstrates attention to detail, accuracy, and analytical thinking in identifying claim discrepancies.
• Accountable for quality work, meeting deadlines, and adhering to RCM compliance and SOPs.

What We Offer:

• Core Benefits & Wellness
  
• Comprehensive Medical, Dental & Vision Insurance (Virtual Care included)
  
• Confidential Employee Assistance Program (EAP) for you and your family
  

Financial Wellness

• Competitive Pay with Bonus Opportunities & Annual Merit Increases
  
• 401(k) Retirement Plan with Company Match
  
• Health Savings Account (HSA) options with HDHP plans
  

Life Insurance Protection

• Company-Paid Basic Life Insurance
  
• Optional Supplemental Life Coverage for You, Your Spouse & Children
  

Time Away & Life Balance

• Generous Paid Vacation (starting at 2 weeks!) + 6 Paid Holidays
  
• Short- and Long-Term Disability Coverage
  
• Supportive Leave of Absence Options