SUMMARY: 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 reviewing reconsiderations submitted by providers, PPO transmission errors, and completing special handling requests as submitted. PRIMARY RESPONSIBILITIES: * Process reconsiderations. * Collaborates with MBR Leadership to develop skills and knowledge. * Guides Bill Review Specialist I/II, in nuances of fee schedules allowances per state guidelines. * Responds to written or verbal inquiries relating to our bill review analysis. Analyzes problems using problem solving skills to determine root cause; communicates and implements solutions. Evaluates medical bills and corresponding EOR's for accuracy and compliance with state mandated fee schedule(s) and our business rules and guidelines. * Reviews PPO Pend & Transmit, validation errors, invalid charges, negative BR allowances, and duplicates. * Completes Special Handling requests from claim handlers as submitted. * 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. * 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. * Ensures provider compliance with the Workers Compensation Health Care Services Rules and Fee Schedule. 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 A. EDUCATION REQUIRED: * High School Diploma or G.E.D. * Certification from AAPC, AHIMA or other nationally recognized organization as a medical coder or biller. If working towards a certification, the certification must be obtained within 6 months of hire date. B. EXPERIENCE REQUIRED: Three to five years of Workers' Compensation Medical Bill Review analysis/repricing and demonstrated experience in processing reconsiderations. C. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: * 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. * Demonstrated attention to detail. * Extensive knowledge of multiple state fee schedules and state reporting procedures. * Working knowledge of PPO networks. * Ability to collaborate across departments. * Ability to problem solve and escalate issues, as needed. D. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: * Background in Workers Compensation preferred. WORKING CONDITIONS: Work is performed in an office setting with no unusual hazards. REQUIRED TESTING: Reading Comprehension, 10 Key, Math, Alpha Numeric, Basic Excel, Basic Word
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