Pre-Billing Quality Specialist

Position Summary

The Pre-Billing Quality Specialist ensures that all billing across IDD (Intellectual and Developmental Disabilities) and BHH (Behavioral Health Home) programs meets payer and regulatory requirements prior to claim submission. This role verifies that all services are fully supported by accurate documentation, appropriate authorizations, and correct utilization.

The Specialist proactively identifies and resolves issues that may delay or prevent billing, working closely with Program teams and Revenue Cycle Management (RCM) to ensure timely and accurate reimbursement.

Key Responsibilities

Pre-Billing Verification

• Review service documentation to ensure compliance with payer-specific billing requirements

• Verify completion of all pre-billing steps, including:

  • Documentation completion

  • Service entry accuracy

  • Authorization validation

  • Unit totals

• Confirm required elements such as:

  • Signatures

  • Timelines

  • Service codes and modifiers

  • Utilization limits

• Identify and coordinate correction of missing or inaccurate documentation

Claims Preparation & Issue Resolution

• Validate service data, authorizations, and payer information prior to claim submission

• Identify and resolve pre-billing issues such as data discrepancies and authorization conflicts

• Collaborate with Program leadership and RCM to address:

  • Denials

  • Returned claims

• Track denial trends and support implementation of corrective actions

Utilization & Authorization Monitoring

• Track service utilization to prevent exceeding authorized limits

• Monitor authorizations for accuracy in:

  • Units

  • Service codes

  • Effective dates

• Notify program staff of discrepancies or upcoming expirations

Reporting & Data Analysis

• Generate and analyze reports from systems such as:

  • Avatar

  • SetWorks

  • Therap

  • BHL

• Produce KPI and pre-billing reports to identify trends and outstanding issues

• Validate billing-related data across multiple EHR platforms

• Ensure documentation supports all billed services

Training & Process Improvement

• Train program staff on billing requirements, documentation standards, and system processes

• Communicate findings and issues clearly to program teams and RCM

• Recommend workflow improvements to enhance accuracy and reduce denials

Administrative Support

• Assist in evaluating and improving workflows related to:

  • Pre-billing and billing processes

  • Consumer change forms

  • Opening/closing service locations

• Perform additional duties as assigned by leadership

Qualifications

Education & Experience

• High School Diploma or GED required; Associate’s degree preferred

• Valid Driver's License minimum of three years.

• 2 years of experience in:

  • Behavioral Health, IDD, or Medicaid-funded billing

• Strong knowledge of:

  • Medicaid billing processes

  • Denials management

  • EHR systems and reporting tools

Technical Skills

• Advanced proficiency in Microsoft Excel, including working with large datasets

• Experience navigating multiple EHR systems

• Knowledge of billing software and reporting tools

Core Competencies

• Strong attention to detail and accuracy

• Excellent organizational and time-management skills

• Analytical and problem-solving abilities

• Effective written and verbal communication

• Ability to manage multiple priorities and meet deadlines

• Ability to work independently and collaboratively

• Solution-oriented mindset with a focus on continuous improvement

Working Conditions & Requirements

• Work is primarily performed in a professional office environment

• Ability to sit for extended periods and use standard office equipment

• Occasional lifting, bending, and movement as required

• Must comply with:

  • HIPAA regulations

  • OSHA and safety standards

  • Organizational policies and procedures

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