Description

Under moderate supervision, 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. This would include analysis for the fee schedule or usual and customary application, as well as PPO interface, while meeting contractual client requirements.

Essential Job Functions:

• 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
• Knowledge of medical terminology, workers’ compensation billing guidelines, and fee schedules, including CPT/ICD/HCPS coding, and knowledge of UB04 and CMS 1500 form types preferred
• 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

Abilities and Competencies:

• 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

Education and Experience:

• High School Diploma or equivalent
• AAPC Coding Certification is 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)

Driving Essential: No

Certifications/Licenses: AAPC Coding Certification (CPC required, CIC preferred)

Position Demands:

This position requires sitting, bending, stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 10 lbs. Ability to learn technical material. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office equipment such as a calculator, copy machine, printer, etc. Some travel may be required.

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.

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.