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 include the following. Other duties may be assigned. 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. EDUCATION AND EXPERIENCE Medical Bill Review Specialist I: 1. High School Diploma or G.E.D is required. 2. Minimum of two years of experience in a medical billing and/or coding position or similar relevant experience that would provide the necessary skills, knowledge and abilities to perform the required responsibilities. Medical Bill Review Specialist II: 1. High School Diploma or G.E.D is required. 2. Degree/Certificate of completion in Medical Coding or Billing is required. 3. Minimum of one year as a Medical Bill Review Specialist I OR Minimum of two years demonstrated experience in workers compensation medical bill review analysis/pricing. QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. OTHER SKILLS AND ABILITIES 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 and Abilities of Medical Bill Review Specialist II: * Knowledge of various state workers' compensation medical payment methodologies. * Demonstrated attention to detail. ADDITIONAL INFORMATION The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment. 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
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