Job Title: Medical Biller (Medicaid & MCO - Behavioral Health)

Position Summary

The Medicaid & MCO Biller is responsible for accurate and timely submission, tracking, and reconciliation of claims for services billed to DC Medicaid and Managed Care Organizations (MCOs). This role ensures compliance with District of Columbia Department of Health Care Finance (DHCF) regulations and payer-specific billing requirements while supporting revenue cycle efficiency.

Key Responsibilities
 

Eligibility & Authorization Verification:

Verify Medicaid eligibility using systems such as DC Access System or other payer portals.
Confirm MCO enrollment and service coverage prior to claim submission.
Track and manage prior authorizations and limitations.
Claims Submission & Processing

Submit clean claims to DC Medicaid and MCOs (e.g., AmeriHealth Caritas DC, MedStar Family Choice DC, Wellpoint, HSCSN)
Ensure proper use of CPT, HCPCS, and ICD-10 codes for behavioral health services.
Verify authorization requirements prior to billing (e.g., therapy, community support, medication management).

Denial Management & Follow-Up:

Review, analyze, and resolve denied or rejected claims.
Initiate timely appeals and resubmissions according to payer guidelines.
Track trends in denials and recommend corrective actions.

Payment Posting & Reconciliation:

Post payments, adjustments, and denials accurately from EOBs/ERAs.
Reconcile accounts receivable and identify discrepancies.
Maintain aging reports and escalate outstanding balances.

Compliance & Documentation:

Ensure billing practices comply with DHCF, Medicaid, and MCO guidelines.
Maintain audit-ready documentation (service notes, authorizations, consents).
Support internal and external audits (e.g., CARF, Medicaid reviews).

Collaboration:

Work closely with clinical, care coordination, and intake teams to ensure all required info and documentation is available for billing.
Provide feedback to staff on documentation errors affecting reimbursement.


Technical Skills:

Knowledge of CPT, ICD-10, and HCPCS coding.
Familiarity with EHR systems (e.g., Credible Behavioral Health or similar).
Proficiency in Office 365

Core Competencies:

Strong attention to detail and accuracy.
Knowledge of DC Medicaid regulations and MCO policies.
Problem-solving skills for denial resolution.
Ability to manage multiple payers and deadlines

Preferred Qualifications:

Experience with CARF-accredited organizations.
Familiarity with services such as:
Community Support Services (CSS),

Intensive in Home and Community Services(CBI)
Assertive Community Treatment (ACT)
Medication Management
Intensive Care Coordination (ICC)
Certification such as Certified Professional Biller (CPB) is a plus.

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