Summary:

Under the supervision of the Senior Director of Quality & Performance, the Billing Quality Specialist is responsible for conducting pre-billing quality reviews to ensure that billing documentation is accurate, complete, timely, and compliant prior to submission by Finance. This position supports billing integrity by reviewing program documentation, identifying missing or insufficient information, communicating findings to program leadership, and ensuring corrective follow-up occurs before claims are released for billing.

The Billing Quality Specialist also supports denial prevention by identifying documentation trends, workflow gaps, and compliance risks that may impact reimbursement. This position works collaboratively with Finance, Quality, Compliance, and program teams to ensure documentation standards are met and that the agency maintains compliance with applicable billing requirements, HIPAA, OMIG expectations, and payer/program-specific regulations.

This position is also responsible for supporting HCBS Life Plan compliance processes, including reviewing Life Plan documentation and related service planning requirements to ensure agency practices align with OMIG compliance expectations and internal quality standards.

Essential Functions:

Reasonable Accommodations Statement

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable Accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

• Conduct pre-billing documentation reviews to confirm services are supported and ready for Finance review prior to claim submission.
• Identify missing, incomplete, inconsistent, or non-compliant documentation and communicate findings to program leadership and applicable staff.
• Track pre-billing issues and follow up to ensure concerns are resolved within required billing timelines.
• Collaborate with Finance regarding documentation readiness, billing questions, and audit findings; Finance remains responsible for final claim submission.
• Support denial prevention by identifying documentation trends, recurring errors, workflow gaps, and compliance risks.
• Perform quality and compliance sampling audits as assigned to assess documentation, billing readiness, and program compliance.
• Prepare and distribute audit reports that summarize findings, trends, corrective action needs, and recommendations for improvement.
• Track and trend audit data to identify risk areas, recurring documentation concerns, and staff training needs.
• Review HCBS Life Plan documentation and related service planning processes to support OMIG compliance.
• Monitor HCBS Life Plan processes, including plan timeliness, documentation completeness, staff follow-up, and communication with applicable program staff.
• Support the development and monitoring of policies, procedures, work instructions, and quality tools related to billing readiness, documentation review, and HCBS Life Plan processes.
• Maintain HIPAA compliance and stay current with applicable billing, documentation, OMIG, and program-specific regulatory requirements.
• Make recommendations for staff training, workflow improvements, and corrective actions based on audit findings and trend analysis.
• Perform other duties as assigned by the supervisor.

Authority:

This position holds a relatively high degree of independence within the framework of the agency’s policies and procedures. The individual must be resourceful and able to display initiative and understanding of management systems and interpersonal relations. Must keep immediate supervisor abreast of issues and concerns which merit intervention from higher level management staff.

Position Qualifications:

Competency Statement(s)

• Analytical Skills - Ability to use thinking and reasoning to solve a problem.
• Accuracy - Ability to perform work accurately and thoroughly.
• Customer Oriented - Ability to take care of the customers’ needs while following company procedures.
• Detail Oriented - Ability to pay attention to the minute details of a project or task.
• Developing Others-Ability to teach or foster the development of others, giving constructive feedback and reassurance after problems.
• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, sexual orientation or job type.
• Ethical - Ability to demonstrate professionalism conforming to a set of values and accepted standards.
• Interpersonal-Ability/desire to understand others’ attitudes/interests/needs/nonverbal behavior, listening skills, and understanding strengths/limitations of others.
• Leadership- Ability to Motivate, influence, and support others to accomplish team and organizational goals.
• Training & Presentation Skills.
• Reliability - The trait of being dependable and trustworthy.
• Communication, Oral - Ability to communicate effectively with others using the spoken word.
• Communication, Written - Ability to communicate in writing clearly and concisely.

Skills and Abilities:

• Valid driver’s license, ability to provide own transportation, and travel to various locations.
• Bilingual in English and Spanish preferred.
• Must be able to perform all functions with minimal supervision.
• Strong knowledge of billing documentation standards, Medicaid-funded service requirements, OMIG compliance expectations, and HCBS Life Plan processes, with the ability to conduct accurate pre-billing reviews, identify documentation risks, track and trend findings, communicate corrective actions clearly, and collaborate effectively with Finance, Quality, Compliance, and program leadership while maintaining confidentiality and role clarity.
• Perform other duties as assigned by the supervisor.
• A combination of training and experience other than the specified, if judged to be adequate for the job, may be considered.

Physical Demands:

The position does require occasional standing, squatting, lifting of up to approximately 10 lbs. And frequent sitting.

Employee Signature: ___________________________________ Date: _________________________

Ibero American Action League is committed to the policy of equal employment opportunity. This policy expressly prohibits discrimination on the basis of sex, race, color, religion, creed, national origin, age, marital status, sexual orientation, disability, gender identity or expression, genetic predisposition or carrier status, domestic violence victim status, veteran status or status as a member of any other protected group or activity