Quality Assurance Insurance Specialist

About the role

At Bioventus, our business depends on developing our people. We invest in you and challenge you to be the best. We value our colleagues for their different perspectives and individual contributions, and our leaders listen. Our success rests on working together to achieve shared goals and rewards. Join a diverse team of global colleagues driven to help patients resume and enjoy active lives.

Responsibilities

• Serves as patient advocate in the appeals process, gathers and compiles sufficient documentation to develop appeals case data for submission to review board.
• Arrange and prepare physicians for peer review.
• Performs retrospective medical necessity reviews to determine appeals after denials have occurred.
• Monitor insurance denials by running appropriate reports and contacting insurance companies to resolve claims denied for clinical reasons.
• Identify coding or clinical documentation issues and work to correct the errors in a timely manner.
• Performs audit review of payer audit accounts and payer medical necessity denials while working closely with the management team on strategies to improve coding QA methods.
• Works towards achieving individual and company goals for cash collections, payer audits, credit balances, medical records, correspondence, appeals/disputes, and accounts receivable over 90 days.
• Receives, documents, processes, and tracks payer audit requests until resolution.
• Assists the liaison between company and outsourced agency(s) focused on appeals processing.
• Conduct analysis on data collected during up front denials, review process, medical payor records and appeals decisions results. Identify problem accounts and escalate as appropriate. Develops and produces reports based on data identified during analysis.
• Holds oneself and others accountable to conduct business in a manner compliant with Bioventus’ Code of Compliance and Ethics, policies and procedures and internal controls applicable to their role.
• Other duties as assigned.

Requirements

• High School diploma or GED required; Associates degree preferred.
• Minimum 5–7 years of experience in insurance compliance, quality assurance, or medical claims within a highly regulated industry, preferably medical devices, healthcare, or pharmaceuticals.
• Knowledge of government program regulations, Medicare, and other third-party payors is required.
• Understanding of business service functions including billing, collection, insurance and appeals.
• Ability to read/interpret medical records and medical policy guidelines.
• Strong organizational and documentation skills with the ability to manage multiple competing priorities.
• Proficient in Microsoft Office Suite and document control or quality management systems.

Benefits

Bioventus invests in you and challenges you to be the best.