Medical Bill Rev Specialist I/II

About the role

The role involves analyzing medical bills for Workers Compensation claims to ensure appropriateness of services billed. It includes using MBR software to determine code appropriateness and ensuring compliance with business rules, client requirements, and state guidelines.

Responsibilities

• Provides QA for basic bills for adjudication within Bill Review system.
• Reviews, analyzes, adjusts, and releases basic bills, including duplicates.
• Affixes to reference library of fee schedules, CPT, ICD-CM, HCPCS, and other industry publications to support findings.
• Affixes to assist all bill review teams as assigned with current work volumes or backlogs to ensure timely payments.
• Identifies system and/or report bill review issues and findings to MBR Leadership.
• Provides a high level of customer service for all business partners and customers.
• Reviews state reporting criteria as related to bill processing and outlined in state guidelines.
• Manages confidential client information with discretion and good judgment in accordance with department and company guidelines.
• Demonstrates a dependable work ethic.
• Responsible for analyzing complex billings for multi-state Workers Compensation medical claims to determine appropriateness of services billed.
• Makes bill review processing determinations according to rules and regulations and/or third-party partners.
• Reviews hospital and surgery billings.
• Reviews, analyzes, adjusts, and releases queued bills to ensure timely payments.
• Ensures provider compliance with the Workers Compensation Health Care Services Rules and Fee Schedule.
• Processes reconsiderations where no previous payment has been issued.

Requirements

• Medical Bill Review Specialist I: High School Diploma or G.E.D., minimum 2 years of experience in medical billing or similar relevant experience.
• Medical Bill Review Specialist II: High School Diploma or G.E.D., degree/certificate in Medical Coding or Billing, minimum 1 year as a Medical Bill Review Specialist I or minimum 2 years of demonstrated experience in workers compensation medical bill review analysis/pricing.

Qualifications

• Basic knowledge of medical terminology, anatomy, and CPT/ICD-CM codes, & medical fee schedule.
• Basic knowledge of computers and ability to enter alpha/numeric data accurately.
• Math skills with the ability to use a ten-key calculator.
• Effective oral, written, and communication skills.
• Ability to consistently meet or exceed daily production and quality standards for this position.
• Excellent organizational skills and ability to prioritize work.
• Ability to work with minimal direction.