SUMMARY: Medical Bill Review Specialist I Primarily responsible for analyzing bills for multi-state Workers Compensation medical claims to determine appropriateness of services billed. Responsible for analyzing simple billings by utilizing our Medical Bill Review (MBR) software to determine appropriateness of codes. Responsible for making bill review processing determinations according to rules, regulations, and/or third-party partners. Medical Bill Review Specialist II Primarily responsible for performing technical review of more complex medical bills, including modifiers, anesthesia, & psychiatric. Responsible for analyzing billings including outpatient hospital and multiple surgeries by utilizing our Medical Bill Review (MBR) software to determine appropriateness of codes and excessive charges. Also responsible for analyzing assigned medical bills to determine compliance with business rules, client specific requirements and multiple state rules, regulations and guidelines. PRIMARY RESPONSIBILITIES: This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required. PRIMARY RESPONSIBILITIES: Medical Bill Review Specialist I: * Provides QA for basic bills for adjudication within Bill Review system. * Reviews, analyzes, adjusts and releases basic bills, including duplicates. * Refers to reference library of fee schedules, CPT, ICD-CM, HCPCS and other industry publications to support findings. * Assist all bill review teams as assigned with current work volumes or backlogs to ensure timely payments. * Identifies system and/or reports 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. Additional responsibilities of Medical Bill Review Specialist II: * Responsible for analyzing complex billings for multi-state Workers Compensation medical claims to determine appropriateness of services billed. * Responsible for making bill review processing determination according to rules and regulations and or third-party partner. * 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. * Process reconsiderations where no previous payment has been issued. EMPLOYMENT QUALIFICATIONS: A. EDUCATION REQUIRED: Level I High School Diploma or G.E.DAnd Enrolled in a medical billing and coding certificate or degree program. Level II Degree/Certificate in Medical Coding or Billing OR Certification from AAPC, AHIM or other nationally recognized organization as a medical Coder or Biller. B. EXPERIENCE REQUIRED: Medical Bill Review Specialist I One year of other relevant experience that provides the necessary skills, knowledge and abilities. Medical Bill Review Specialist II Two years as a Medical Bill Review Specialist I. OR Degree/Certificate or Certification in Medical Coding or Billing with a minimum of 2 years demonstrated experience in workers' compensation medical bill review analysis/pricing. C. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: Medical Bill Review Specialist I: * 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. Ability to use reference manuals and apply information to medical claims * Excellent organizational skills and ability to prioritize work. * Ability to work with minimal direction. Additional Skills/Knowledge/Abilities of Medical Bill Review Specialist II: * Knowledge of various state workers' compensation medical payment methodologies. * Demonstrated attention to detail. D. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: * Additional training or coursework in a medical field preferred. * Medical Billing/Coding diploma preferred. * Background in Workers Compensation preferred. WORKING CONDITIONS: Work is performed in an office setting with no unusual hazards. REQUIRED TESTING: Medical Bill Review Specialist I: Basic Windows, Reading Comprehension, Alpha Numeric, 10 Key, and Math Medical Bill Review Specialist II: Reading Comprehension, 10 Key, Math, Alpha Numeric, Basic Excel
