Senior Med Bill Rev Specialist

SUMMARY:

Primarily responsible for analyzing complex billings including hospital, surgery center and surgeries by utilizing our Medical bill review software to determine appropriateness of codes, excessive charges, and unbundling of codes. Responsible for making coding determinations according to rules and regulations for each state jurisdiction. Review, analyze and resolves medical bill disputes in a prompt and accurate manner. Through an individual, interactive and strategic approach negotiates medical bills with medical providers.

PRIMARY RESPONSIBILITIES: 

· Reviews and negotiates bills

· Researches, verifies and analyzes Medicare guidelines and PPO contracts to apply appropriate discounts to medical claims.

· Responds to medical fee disputes on bill review. Analyzes mediation using problem solving methodology skills to determine appropriate action (payment or continued denial). Communicates and implements solutions.

· Handles confidential client, financial and employee information with discretion and good judgment in accordance with our department and Company guidelines.

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

A. EDUCATION REQUIRED: 

· Reviews, prioritizes work. Monitors workflow to ensure daily production is completed in a timely manner.

· Evaluates complex medical bills and reports to ensure that coding, billing forms, and diagnosis are all related to the covered injury.

· Pays bills in accordance with mandated fee schedule(s) and our business rules, or disallows payment and generates an explanation of benefits telling the provider why payment was denied.

· Responds to written or verbal provider and business partner inquiries relating to our bill review analysis. Analyzes problems using problem solving

· Reviews, analyzes, adjusts and releases queued bills, including validation errors, manual reviews, and technical reviews and or P&T bills.

· Process reconsiderations and refund requests, as needed.

· Reviews and audits (do they audit?) high level technical bills.

· Act as a resource for other team members.

· Reviews (EOR) for accuracy and compliance with State mandated fee schedules(s) and our business rules and guidelines.

· Methodology skills to determine root cause; communicates and implements solutions.

· Refers to reference library of fee schedules, CPT, ICD-9/10, HCPCS and other industry publications to research and support findings.

· Identifies problems, provides solutions and resolves promptly. Escalates more complex issues appropriately.

Associates degree insurance, business or related field. College courses in medical billing and coding required. Combination of relevant education and work experience may be considered in lieu of a degree.

B. EXPERIENCE REQUIRED:

Two years as a Medical Bill Review Specialist II, or one year as a Provider Relations Specialist and working knowledge of three or more state payment methods.

OR,

Four or more years in medical bill review and/or evaluating complex services (i.e. med-legal, Consults, multiple surgical or hospital), including two years previous medical bill review experience in a Workers Compensation industry which provides working knowledge of payments in three or more payment methodologies.

C. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: 

· Ability to proofread documents for accuracy of spelling, grammar, punctuation and format.

· Excellent organizational skills and ability to prioritize work.

· Ability to consistently meet or exceed daily production and quality standards for this position.

· Strong analytical and problem solving skills.

· Basic knowledge of computers with ability to enter accurately 40 WPM.

· Basic knowledge of word processing.

· Intermediate knowledge of spreadsheet software.

· Effective oral, written, communication and customer service skills.

· Math skills with the ability to use a ten-key calculator.

· Ability to manage work with minimal direction.

· Extensive Knowledge of Workers Compensation Fee Schedule(s), compliance regulations, Medicare guidelines, RVS/CPT/ICD-9/10, and other healthcare programs.

· Ability to use reference manuals and apply information to medical claims.

· Demonstrated attention to detail.

· Ability to read, analyze and interpret contracts and governmental regulations.

· Assist all teams as assigned, with current work volumes or backlogs.

· Enters information into our bill review system for coding determination and/or evaluate bills for appropriateness coded by another analysis (un-hold process).

· Working knowledge of anatomy, surgery codes and medical terminology.

· Ability to review operative reports.

· Thorough knowledge of Workers Compensation Health Care Services Rules and methodologies for multiple states.

D. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: 

· Bachelors Degree in insurance, business or related field.

· Medical Billing/Coding certification (American Academy of Professional Coders, American Health Information Management Association (AHIMA)

· Certified Authority on Workers Compensation (CAWC)

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

REQUIRED TESTING: 

Reading Comprehension, 10 Key, Math, Typing 40wpm, Proofreading, Basic Word, Intermediate Excel, Basic Windows