Coder – Specialty Medical Bill Reviewer

📋 Description

• Oversee the review, auditing, and data entry of medical bills across various states and business lines within both Worker’s Compensation and Commercial Health sectors.

• Conduct audits on medical bills to verify their appropriateness and compliance with State Fee Schedules, customer guidelines, and PPO discounts.

• Perform analysis and review for one or more assigned states that have fee schedules.

• Utilize Fee Schedules, Online Documents, Client instructions, and other training materials to accurately assess medical bills.

• Evaluate medical bills for compensability and their connection to injuries.

• Reprice medical bills according to Workers’ Compensation Fee Schedule and PPO Network standards.

• Investigate usual and customary/fee schedule applications and system interfaces as necessary.

• Review specialized Medical Bills, which include those from hospitals, surgeries, and high-level physicians.

• Determine reimbursement outcomes by applying Fee Schedule reductions, PPO reductions, Usual and Customary reductions, or Medicare reductions.

• Communicate and justify to providers and clients the rationale behind the methodologies used to achieve charge reductions.

• Analyze and review high-level office visits, reports, and medical record reviews.

• Interpret hospital review guidelines for both inpatient and outpatient claims.

• Responsible for generating a final review for payment recommendations to the client.

• Maintain productivity levels, along with speed and accuracy, as defined by company standards.

⛳️ Requirements

• Up-to-date knowledge of utilization review processes and managed care practices.

• Familiarity with state-specific fee schedules.

• Strong understanding of Medical Terminology and CPT/ICD-9/ICD-10 coding systems.

• Capability to identify trends through analysis of practices to enhance resource utilization and cost management.

• Ability to communicate identified trends through analytical studies using various reporting methods.

• Proficient in working both collaboratively and independently while achieving productivity targets.

• Experience working in a high-production environment while adhering to productivity and quality standards.

• Ability to represent Utilization Management in assigned organizational committees.

• Excellent skills in relationship management.

• Proven problem-solving abilities in complex situations.

• Capacity for abstract thinking.

• Strong organizational skills and ability to prioritize tasks effectively.

• Proficient analytical, numerical, and reasoning skills.

• Well-honed interpersonal skills.

• Ability to build credibility and make decisive choices while supporting the organization’s preferences and priorities.

• Results-driven with the ability to balance various business considerations.

• Knowledge of multi-state workers’ compensation systems.

• Proficient in Microsoft Office products and database software.

• Ability to create grammatically correct reports utilizing standard medical terminology.

• Must have a proven track record of producing highly accurate work with a keen attention to detail.

🏝️ Benefits

• Equal Employment Opportunity (Our EEO Statement): The Company is a veteran-owned organization that provides Equal Employment Opportunities (EEO) to all Team Members and job applicants without discrimination based on race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or any medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran according to applicable federal, state, and local laws, or any other characteristic or class protected by law. We are dedicated to providing equal employment opportunities.

• The Company adheres to applicable state and local laws regarding non-discrimination in employment. This policy encompasses all aspects of employment, including, but not limited to, hiring, promotion, termination, pay, fringe benefits, membership, job training, classification, and other employment conditions. We strive to foster an inclusive environment for all team members and applicants and value the unique skills and experiences that veterans contribute to our team, encouraging them to apply.