High Dollar Review Specialist

About The Role

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high dollar claims for appropriate and accurate billing, pricing and adjudication. This individual will play a key role in the Quality Department and interact with many internal and external stakeholders.

Primary Responsibilities

• Review high dollar claims to ensure claim was priced and billed correctly including implant and supply charges, observation room charges, units billed for drugs and procedures
• Review DRG for accuracy as compared to billed procedures, diagnosis/condition, age, etc
• Develop reporting mechanism to track pertinent claims information related to high dollar claims
• Collaborate review efforts with CMO, Legal and other departments as needed
• Coordinate efforts with external vendors as required

Essential Qualifications

• Significant experience in dealing with facility-based billing
• Experience with physician/ancillary billings
• Expertise in DRG Groupers
• Candidate should have at least 3-5 years or more of coding and claims examination experience
• Working knowledge of Drug Reimbursement methodologies including AWP and ability to calculate J code reimbursements
• Familiarity with hospital billing systems and methodologies and healthcare terminology
• Impeccable follow up, organization, and time management skills
• Work well with all levels of management internally and externally also with the ability to work independently
• Confident, patient, work well with others, not afraid to ask questions, open to learning
• Great communication skills (both written and oral)