Pacific Health Group (PHG) is a California-based integrated care organization delivering Enhanced Care Management (ECM), Community Supports (CS), and Behavioral Health (BH) services under the CalAIM framework. The organization serves Medi-Cal members across multiple counties through contracts with managed care plans and county behavioral health systems.
The Billing Auditor role sits between service delivery and revenue collection. This position ensures claims are paid correctly and completely, audits claims and remittance activity, investigates underpayments, and helps build processes that prevent revenue leakage.
Key responsibilities include auditing claims against EOBs, 835 remittance advices, and payment records; reviewing PEPM payments against enrollment rosters and rate schedules; identifying denials, zero-pays, and discrepancies; preparing appeals; cross-referencing clinical documentation and EHR records against claims; verifying HCPCS, CPT, and ICD-10 coding; building audit dashboards; and producing monthly revenue reconciliation reports.
3+ years of experience in medical billing, claims auditing, or revenue cycle management in healthcare.
Hands-on experience auditing EOBs, reconciling payments, and managing denials and appeals.
Working knowledge of HCPCS, CPT, and ICD-10 coding.
Proficiency with EHR and billing systems, plus strong Excel or Sheets skills for data analysis.
Strong analytical skills and attention to detail.
Bachelor's degree in healthcare administration, HIM, business, accounting, or equivalent experience.
Preferred qualifications include experience with Medi-Cal managed care, CalAIM (ECM/CS), behavioral health billing, PEPM/capitated payment models, CPC or CCS certification, knowledge of 837/835 electronic transaction standards, and experience in community health, FQHCs, or integrated care settings.
401(k) matching
Dental insurance
Health insurance
Life insurance
Paid time off
Vision insurance
Location
California, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$49,920 - $56,160
Remote work allowed
No
Posted
2 months ago