About this role
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