Role Overview

Responsible for auditing medical bills to ensure that they are appropriate and adhere to the State Fee Schedules, customer guidelines, and PPO discounts
Analysis and review of 1 or more assigned states having fee schedules
Utilize Fee Schedules, Online Documents, Client instructions, and other training material to properly review medical bills
Review medical bills for compensability and relatedness to injury
Reprice medical bills to Workers’ Compensation Fee Schedule and PPO Network
Research usual and customary/fee schedule applications and system interface as appropriate
Reviews specialized Medical Bills, which include hospital, surgery, and high-level physician bills for workers' compensation and non-workers' compensation claims, and may include hospital bills, auto liability, and usual and customary reimbursement
Determines the appropriateness of a final reimbursement outcome by making the distinction between and knowing when to apply either Fee Schedule reduction, PPO reduction, Usual and Customary reduction, or Medicare reduction
Communicates and defends to providers and clients the basis for the methodology used to accomplish the reduction of charges
Analyzes and reviews high-level office visits, reports, and record reviews
Interprets hospital review guidelines for both inpatient and outpatient claims
Responsible for producing a final review for the recommendation of payment to the client
Maintain productivity, as well as speed and level of accuracy, as determined by company standards

Requirements

Current knowledge of utilization review processes and managed care
Knowledge of state-based fee schedules
Strong knowledge of Medical Terminology and CPT/ICD-9/ICD-10 coding
Ability to identify trends through analysis of practices to improve the overall utilization of resources and cost containment
Ability to communicate those trends found through analytical study using a variety of reporting mediums
Ability to work collaboratively and independently while meeting productivity standards
Ability to work in a high-production environment while meeting productivity and quality standards
Ability to represent Utilization Management in organizational committees, as assigned
Excellent relationship management skills
Demonstrated ability to problem-solve in complex situations
Ability to engage in abstract thought
Strong organizational and task prioritization skills
Strong analytical, numerical, and reasoning abilities
Well-developed interpersonal skills
Ability to establish credibility and be decisive – while also recognizing and supporting our organization’s preferences and priorities
Results-oriented with the ability to balance other business considerations
Knowledgeable of multi-state workers’ compensation systems
Computer literacy on Microsoft Office products and database programs
Ability to construct grammatically correct reports using standard medical terminology
Must have a track record of producing highly accurate work, demonstrating attention to detail
High School Diploma or equivalent
AAPC Coding Certification required (CPC required, CIC preferred)
ICD-9, ICD-10, PCS/HCPS/CPT, MS-DRG, and Geographical codes, and NCQA regulatory compliance guidelines
Must have a consistent coding rate at the 95th percentile or higher
RAC review and auditing
Proficiency as a Specialty Medical Bill Reviewer with two or more years of previous experience in medical bill review (workers’ compensation is a plus)

Benefits

Equal Employment Opportunities (EEO)
Inclusive environment for all team members and applicants
Encourages veterans to apply

NEXUS

Open Positions (1)

Healthcare

Coder – Specialty Medical Bill Reviewer