Senior Claims Specialist at Illumination Foundation – Santa Ana, California

Homelessness is the largest social and public health crisis in California. Illumination health + home is a growing non-profit organization dedicated towards disrupting the cycle of homelessness by providing targeted, interdisciplinary services in our recuperative care centers, emergency shelters, housing services and children's and family programs. IF currently has 13+ facilities with 22+ micro-communities scattered across Orange County, Los Angeles County and the Inland Empire.

Job Description
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. This position plays a critical role in supporting the organization’s revenue cycle by ensuring claims meet payer requirements, coordinating with internal departments, and maintaining compliance with state and contractual billing standards.

The pay rate for this role is $30-32 per hour.
The schedule for this role is a hybrid schedule with Monday/Thursday in office and Tuesday/Wednesday/Friday WFH.

Responsibilities:

CalAIM Billing & Claims Management

• 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.

• Documentation, Coding & Data Review

• 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.

• Denials, Disputes & Follow-Up

• 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.

• Payment Posting & Reconciliation

• 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.

• Compliance, Quality Assurance & Reporting

• 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.

• Interdepartmental Collaboration

• 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.

• Projects & Additional Duties
  
  Expectations:

• Maintain clear, timely, and professional communication with colleagues, supervisors, and external partners to ensure smooth coordination, accurate information sharing, and efficient workflow.

• Must be motivated to work independently and in a group setting.

• Effective communication with providers, departments, and payers.

• Ability to prioritize tasks and meet timelines.

• Be able to meet targets and work under pressure with a high volume of claims

• Consistent adherence to regulatory and payer guidelines.

• Proactive approach to resolving billing and documentation challenges.

Minimum Qualifications/Preferred Experience:

Required:

• 1–3 years of experience in medical billing, preferably in behavioral health, Medi-Cal, or CalAIM programs.

• Knowledge of ICD-10, CPT/HCPCS coding, and standard billing practices.

• Experience reviewing EOBs, RAs, and payer adjudication messages.

• Familiarity with authorization management and eligibility verification processes.

• Strong attention to detail and ability to work with a high level of accuracy.

Proficiency with billing software, EHR systems (e.g., Kipu), and payer provider portals.

Preferred:
​​​​​​​

• Experience with CalAIM or Medi-Cal Managed Care billing.
• Knowledge of DHCS policies, CalAIM documentation requirements, and state billing mandates.
• Understanding revenue cycle management and claim lifecycle workflows.
• Prior experience with appeals, PDRs, or complex denial management.

Benefits:

• Medical Insurance funded up to 91% by Illumination Health + Home (Kaiser and Blue Shield), depending on the plan
• Dental and Vision Insurance
• Life, AD&D and LTD Insurance funded 100% by Illumination Health + Home
• Employee Assistance Program
• Professional Development Reimbursement
• 401K with Company Matching
• 10 days vacation PTO/year
• 6 days of sick pay/year
• Potential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans