Clinical Review Specialist

We are seeking a Clinical Review Specialist with a background in surgery or surgical training to join our medical bill review company. In this role, you will make a meaningful impact in healthcare by ensuring accurate medical billing, verifying appropriate care, and helping manage healthcare costs efficiently. In addition to having appropriate surgical knowledge and experience, we are seeking candidates who are confident and willing to learn. Good communication skills and the ability to work with others outside of the medical review department are essential. You will report to the Chief Medical Officer.

• Meticulously review process to ensure that patient medical records and billing conform with established medical guidelines and insurance medical criteria.
• Understands and maintains current industry knowledge on reimbursements' operational aspects and workflows, including group health, workers’ compensation, automobile, and other common insurances.
• Provides expert coding analysis to discover upcoding used to inflate billed charges.
• Audit medical files to determine whether the medical provider’s documentation complies with all federal and state regulations.
• Utilize current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature for decision-making.
• Ensure providers follow all acceptable coding practices.
• Utilizes company resources to attend trainings, seminars, and other continuous development activities.
• Acts as a central resource to the team for guidance regarding medical billing questions. 
• Maintains punctual, regular, and predictable attendance.  
• Works collaboratively in a team environment with a spirit of cooperation.
• Other duties & special projects, as assigned and based on business needs.

• Physician Assistant (PA) with seven to ten years of experience and/or training as a physician or surgeon.
• Minimum of 2 years of clinical experience, with a strong understanding of medical records and healthcare protocols.
• Strong desire to learn a new side of medicine and engage in a transformative company.
• Ability to perform essential duties with or without reasonable accommodation and without posing a direct threat to the safety or health of employees or others.
• Knowledge of URAC and relevant State and Federal compliance guidelines is recommended but not required.
• Strong attention to detail with excellent verbal and written communication skills.
• Proficient in MS Office suite (Excel, Word, Outlook).
• Ability to use and learn various computer applications (e.g., internal bill review software).
• Good interpersonal and organizational skills.
• Ability to meet deadlines, work independently, and manage time effectively.
• Highly self-motivated and able to partner effectively with cross-functional teams to achieve desired business results.
• Experience in medical billing, claims review, or utilization management is preferred.