Medical Billing Specialist

Position Summary

The Medicare Billing Specialist is responsible for the accurate and timely billing of Medicare claims within the Matrix EMR system for home health services. This role ensures compliance with all Centers for Medicare & Medicaid Services (CMS) regulations while optimizing reimbursement and minimizing denials.

This position works cross-functionally with intake, clinical staff, and leadership to ensure documentation integrity, timely claim submission, and overall revenue cycle performance.

Key Responsibilities

Billing & Claims Management

• Process and submit PDGM NOAs (Notice of Admission) and final claims accurately & timely within Matrix EMR
• Review patient episodes to ensure billing readiness, including validation of OASIS, orders, and visit utilization
• Managed Care, Commercial Insurance, PPO/HMO, Workers Comp and Self-Pay assistance as needed

Accounts Receivable & Follow-Up

• Monitor claim status and aging reports within Matrix EMR & clearing house
• Follow up with Medicare and other PDGM payors on unpaid, denied, or rejected claims promptly
• Investigate root causes of denials and implement corrective actions & appeals
• Rebill corrected claims in a timely manner

Compliance & Documentation Review

• Ensure all claims meet CMS and PDGM billing requirements
• Validate documentation supports billed services, prior to claim submission
• Identify and resolve any documentation gaps in collaboration with clinical teams
• Maintain audit-ready files at all times

Collaboration & Communication

• Partner with intake and clinical teams to ensure clean claims
• Communicate trends, issues, and opportunities for improvement to leadership
• Assist with month-end billing close and reporting

Key Performance Indicators (KPIs)

The Medicare Billing Specialist will be evaluated based on the following metrics:

• Clean Claim Rate: ≥ 95% (claims accepted on first submission)
• Days to Bill (Final Claim Submission): ≤ 5 days from episode end
• NOA Timeliness: 100% submitted within 5 calendar days of SOC
• Denial Resolution Time: First Follow-Up ≤ 72 hours, subsequent follow-up ≤ 14 business day frequency
• Accounts Receivable (AR) > 60 Days: ≤ 20% of total AR
• Productivity: Minimum of 20-25 outstanding claims processed per day (customize based on volume)
• Audit Accuracy Score: ≥ 98% compliance on internal audits

Qualifications

• Minimum 2+ years of Medicare billing & collections experience in home health
• Hands-on experience with Matrix EMR (or similar home health EMR systems)
• Strong knowledge of CMS, PDGM, and home health billing regulations
• Experience managing NOAs, final claims, and denials
• Experience with Medicare Advantage
• Knowledgeable with eligibility and authorizations
• High attention to detail and strong organizational skills
• Ability to work in a fast-paced, deadline-driven environment
• Ability to work independently and manage multiple priorities effectively
• Comfortable with discussing eligibility and outstanding copay, coinsurance, and deductible balances with patients
• Proficiency in Microsoft Office (particularly Excel) & Google

Preferred Qualifications

• Experience with Non-PDGM payers
• Knowledge of ADRs, audits, and compliance reviews
• Medical billing codes & terminology (ICD-10, CPT, HIPPS, etc)
• Knowledge of Healthcare First is an asset
• Experience with DDE & iQIES is an asset

Key Competencies

• Accountability and ownership
• Strong analytical and problem-solving skills
• Effective communication and teamwork
• Time management and prioritization
• Commitment to compliance and continuous improvement

Job Type: Full-time

Pay: $25.00 - $30.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Application Question(s):

• Do you have experience billing with Medicare?

Work Location: Hybrid remote in San Diego, CA 92123