Remote Clubhouse Billing Specialist; Per Diem Claims

Company:
Pacific Health Group
Department:
Revenue Cycle / Billing
FLSA Status:
Non-Exempt, Full-Time
Pay Range: $24 – $26 per hour

Position Summary

The Clubhouse Billing Analyst owns the end-to-end revenue cycle for Clubhouse Services claims submitted under San Diego County's BH-CONNECT Clubhouse Services benefit. Unlike traditional fee-for-service behavioral health billing, Clubhouse Services is reimbursed through a county-specific daily bundled (per diem) rate claimed through the county SMHS delivery system. This role is responsible for translating daily member attendance and service documentation into clean, compliant claims;

managing eligibility, denials, and reconciliation; and serving as the billing subject matter expert on DHCS BH-CONNECT claiming guidance (including BHIN 25009, the BH-CONNECT EBP Policy Guide, and County of San Diego Behavioral Health Services billing requirements).

This is a hands-on role for a billing professional who is comfortable operating in a new benefit with evolving guidance — building billing workflows from the ground up, monitoring DHCS and County claiming updates, and partnering closely with program staff to make sure documentation supports every claimed day of service.

Essential Duties and Responsibilities

Claims Production & Submission

• Prepare, scrub, and submit daily bundled rate claims for Clubhouse Services through the County of San Diego's designated claiming system/EHR and Short Doyle/Medi Cal process, in accordance with County and DHCS requirements.
• Apply correct procedure codes, modifiers, place-of-service, and rendering/billing provider data per BHIN 25009, the BH-CONNECT EBP Policy Guide, and County billing manuals.
• Reconcile daily Clubhouse attendance logs and service documentation against claimable member days before submission; flag undocumented or unsupported days to program leadership prior to claiming.
• Track and comply with timely filing requirements and County claim submission calendars.

Eligibility & Authorization

• Verify Medi Cal eligibility and aid codes for all Clubhouse members monthly (and prior to claiming), including share-of-cost, other health coverage (OHC), and managed care assignment issues that affect SMHS claiming.
• Coordinate resolution of eligibility discrepancies with program staff and County BHS as needed.

Denials, Corrections & Reconciliation

• Work claim denials, disallowances, and voids/replacements; perform rootcause analysis and correct/resubmit within required time frames.
• Reconcile remittances (835s/EOBs) against submitted claims; maintain accurate accounts receivable aging and escalate underpayments or unpaid claims.
• Prepare monthly revenue reconciliation reports (claimed vs. paid vs. expected at the County bundled rate) for leadership.

Compliance & Audit Readiness

• Maintain working knowledge of BHCONNECT Clubhouse Services requirements, including the daily bundled rate structure, medical necessity/eligibility criteria, and documentation standards; monitor DHCS BHINs and County BHS updates for claiming changes.
• Understand the Clubhouse International Accreditation requirement and its impact on claiming eligibility (Medi Cal claiming is limited to four years total prior to Accreditation); support leadership in tracking accreditation-linked billing status.
• Support internal charter-claim audits and respond to County/DHCS audit requests, recoupments, and cost report or data submissions as assigned.
• Ensure all billing activity complies with HIPAA, 42 CFR Part 2 (where applicable), and Medi Cal program integrity requirements; report suspected compliance issues immediately.

Cross-Functional Support

• Serve as the billing liaison to County of San Diego BHS billing/fiscal contacts for Clubhouse Services claiming questions.
• Train Clubhouse program staff on documentation elements required to support the daily bundled rate.
• Assist with billing workflow buildout, desk procedures, and QA processes for this new service line; support billing for other PHG lines of business as capacity allows.

Minimum Qualifications

• 3+ years of medical billing experience, with at least 1 year in behavioral health, Medi Cal, or county Specialty Mental Health Services (SMHS) billing.
• Working knowledge of Medi Cal eligibility verification, aid codes, and claim adjudication (837/835 transactions, denial codes, void/replace processes).
• Experience with an EHR/practice management system used for behavioral health claims (e.g., Smart Care, Cerner/CCBH, Netsmart, or comparable).
• Strong Excel skills (pivot tables,…