Responsible for reviewing, auditing, and data entry of medical bills for multiple states and lines of business within both Worker’s Compensation and Commercial Health arenas.
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
Determine reimbursement outcomes by applying 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.

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.

Equal Employment Opportunity (Our EEO Statement): The Company is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities.
The Company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. We are committed to creating an inclusive environment for all team members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.

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