Casualty Bill Review Specialist

Primary Responsibilities

• Bill Review & Regulatory Compliance:
• Review medical bills for accuracy, coding validity, and compliance with New York Workers’ Compensation Board (WCB) regulations.
• Apply New York Medical Treatment Guidelines (MTGs).
• Ensure proper application of New York fee schedules and reimbursement methodologies.
• Evaluate medical narratives and attachments.
• Ensure compliance with prompt payment requirements.
• Rules, Workflow & Pricing Management:
• Configure and maintain bill review rules and workflows.
• Partner with Network and Operations for pricing implementation.
• Maintain monitoring system outputs and recommend improvements.
• Cross-Functional Collaboration:
• Collaborate with Network, Operations, IT, and vendors.
• Ensure alignment of bill review strategies and processes.
• Training & SME Responsibilities:
• Serve as SME for New York bill review.
• Develop and deliver training programs.
• Create job aids and documentation.
• Disputes & Compliance:
• Collaborate with team members on denials, reconsiderations, and dispute processes.
• Ensure WCB compliance and audit readiness.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

Job Alert Fraud

We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated on brighonthps.com/Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected].