Senior Substance Abuse Claims/Collections Specialist

REPORTS TO: Director of RCM 

EMPLOYMENT STATUS: Full-Time

CLASSIFICATION: Non-exempt

LOCATION: Van Nuys, CA

WORK LOCATION: On Site

WORK HOURS: 8:00AM-4:30PM Monday-Friday

Job Summary:

The Senior Substance Abuse Claims/Collections Specialist at CodeMax is responsible for ensuring timely and accurate claim submissions, reducing denials, and optimizing reimbursement processes. The specialist will work closely with insurance companies to rectify payment denials, settle disputes, and receive due reimbursements. The ideal candidate will possess strong communication skills, a deep understanding of medical billing and coding, and the determination to resolve outstanding claims.

Key Responsibilities:

1. Claims Processing & Accuracy

• Ensure timely and accurate claims submission in accordance with payer requirements and industry regulations.
• Monitor claims scrubbing processes to minimize rejections and denials
• Follow-up on claims corrections, resubmissions, and appeals for denied claims

2. Denials & AR Management

• Analyze denial trends and implement strategies to improve claim acceptance rates
• Collaborate with the Appeals and AR teams to resolve outstanding claims and negotiate underpayments
• Ensure follow-up on all unpaid claims over 30+days and escalate problematic claims as needed

3. Compliance & Quality Assurance

• Ensure claims processing align with HIPAA, payer guidelines, and regulatory compliance requirements
• Work closely with the coding and clinical documentation teams to prevent claim denials due to documentation errors

4. Reporting & Process Improvement

• Identify bottlenecks in claims workflows and implement process improvements
• Collaborate with billing, VOB, and UR teams to optimize revenue cycle efficiency.

Key Performance Indicators (KPI's):

• Clean Claim Rate: ≥ 95%
• Denial Rate: ≤ 10%
• AR Days Outstanding: ≤ 30 days
• Appeal Success Rate: ≥ 75%
• Claims Submission Turnaround: ≤ 48 hours post-service

Qualifications & Experience:

        Education:

• Bachelor’s degree in Healthcare Administration, Business, Finance, or related field preferred
• Equivalent work experience in RCM or medical billing/claims will be considered

Experience:

• 3-5 years of experience in medical claims processing, billing, or revenue cycle management
• Strong knowledge of payer guidelines, insurance contracts, and reimbursement models (Medicare, Medicaid, Commercial).

Skills & Competencies:

• Claims & Denial Management Expertise - Ability to identify trends and implement corrective actions.
• Analytical & Problem-Solving Skills – Strong ability to analyze AR and claim data to drive improvements
• Communication & Negotiation Skills - Ability to interact professionally with payers, clients and internal teams
• Technical Proficiency – Experience with RCM software, payer portals and EHR systems

Benefits

·       Health Insurance

·       Vision Insurance

·       Dental Insurance

·       401(k) plan with matching contributions