Certified Code Reviewer, Clinical Validation

Company Details

Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured worker’s successful and speedy return to work is good for people and good for Berkley’s insurance operating units. BMMS was started in 2014 by reimagining the relationship between medical need and technology as a way to deliver the best outcome for injured workers and Berkley’s operating units. Our goal was clear: combine solid clinical practices, proven return-to-work strategies and robust software into one system for seamless management of workers’ compensation cases.

To get it right, we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give Berkley companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology, software platforms, data analytics and professional services ensures we provide Berkley’s operating units with reliable results, and reduced time and expenses associated with case management.

Responsibilities

As a Certified Code Reviewer , Clinical Validation you will be an essential member of the workers’ comp managed care and cost containment team . As a vital part of our workers’ comp managed care team, you’ll assist with the clinical medical bill review operations. Ideal candidates should have a strong background in bill review, managed care operations, and workers’ comp regulations. Excellent communication, analytical, and organizational skills are a must.

• Analysis of the clinical medical bill review process, ensuring accuracy and compliance.
• Provide quality audits of the clinical validation code review team.
• Assist Director of Clinical Services with design and documentation of clinical protocols and ensure regulatory adherence.
• Participate in the ongoing education and training of the clinical validation team; be the go-to expert on code review products.
• Collaborate with cross-functional teams, especially IT and data analysis team for product launches and technical automations.
• Update Rule Guidelines on a quarterly basis
• As part of the clinical validation team: conduct code reviews
• Provide oversight and review bills sent for reconsideration
• Provide SME guidance for internal negotiations for complex bills
• Evaluate market trends and provider billing practices to enhance bill review and clinical validation process to generate increased savings
• Maintains reporting and tracking of issues and escalates items in a timely manner to necessary parties when complex issues arise
• Establish and maintain exceptional working relationships with unit staff, clients, providers, and other departments
• Maintains reporting and tracking of issues and escalates items in a timely manner to necessary parties when complex issues arise
• Must always exhibit professional behavior while representing or being identified as an employee of BMMS.
• Demonstrate the use of tact and discretion in all communications and provide a positive contribution to the morale of the department
• Establish and maintain exceptional working relationships with unit staff, clients, providers, and other departments
  
  

Qualifications

• Experienced, professional certified code reviewer/coder; CPC designation;
• 5 years of experience in medical bill review, clinical research, product development, or related field(s).
• Strong analytical, problem-solving, and project management skills
• Excellent communication and collaboration abilities
• Familiarity with regulatory requirements related to bill review, bill coding
• Ability to effectively prioritize and manage time to meet deadlines
  
  

Education

• Certified Code Reviewer; CPC designation
• Associates Degree or higher
  
  

Additional Company Details

www.berkleymms.com

The Company is an equal employment opportunity employer

We do not accept any unsolicited resumes from external recruiting agencies or firms.

The company offers a competitive compensation plan and robust benefits package for full time regular employees including:

• Base Salary
• Benefits: Health, Dental, Vision, Life, Disability, Wellness, Paid Time Off, 401(k) and Profit-Sharing plans.
  
  

The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment.

Additional Requirements

• Domestic U.S. travel required (up to 10% of time)