Medcicaid Billing,Authorization & Compliance Specialist

Key Responsibilities Medicaid Billing & Claims Processing Prepare, review, and submit Medicaid claims accurately and within required deadlines.

Monitor claim payments, denials, rejections, and outstanding balances.

Investigate and resolve billing discrepancies and claim issues.

Reconcile payments and maintain accurate billing records.

Ensure all billed services comply with Medicaid requirements, approved authorizations, and applicable regulations.

Follow up on unpaid claims and outstanding balances.

Work closely with the clinical and administrative teams to resolve billing concerns.

Authorization & Scheduling Coordination Verify Medicaid eligibility, insurance coverage, and service authorizations.

Track Prior Authorization Requests (PARs), approval statuses, expiration dates, and authorized service units.

Monitor upcoming authorization expirations and initiate timely follow-ups.

Communicate approved authorizations and service changes to the scheduling team.

Coordinate with the Skilled Nursing Team to ensure scheduled services align with approved authorizations.

Identify missing authorizations, scheduling discrepancies, and potential billing concerns.

Communicate with case managers, Medicaid representatives, and internal staff regarding authorization issues.

Attendance, EVV & Documentation Management Review and reconcile daily attendance, visit records, and service documentation.

Verify that billed services accurately reflect services provided.

Monitor Electronic Visit Verification (EVV) records for accuracy and completeness.

Identify missing documentation, incorrect billing units, and visit discrepancies.

Coordinate with clinical staff to resolve documentation concerns before claims are submitted.

Maintain accurate and organized records to support Medicaid billing and regulatory compliance.

CHAP Accreditation & Survey Readiness Maintain ongoing readiness for CHAP accreditation surveys and regulatory inspections.

Organize, maintain, and regularly update CHAP survey readiness binders, both physical and electronic.

Ensure required policies, procedures, committee meeting minutes, logs, and compliance documentation are current and readily accessible.

Monitor survey readiness checklists and identify missing, incomplete, or outdated documentation.

Coordinate with the Director of Nursing, Administrator, and department managers to maintain compliance with applicable CHAP standards.

Assist with preparing documentation for initial, renewal, and unannounced surveys.

Support mock surveys, internal compliance reviews, and corrective action follow-ups.

Track identified deficiencies and assist with maintaining Plans of Improvement (PIPs) and supporting documentation.

Maintain organized records of quality assurance activities, audits, and regulatory compliance efforts.

Assist leadership with ensuring the agency remains survey-ready throughout the year.

Administrative & Reporting Responsibilities Prepare and maintain billing, authorization, attendance, and comp...