Coder / Specialty Medical Bill Reviewer (Remote)

Job Type

Full-time

Description

The remote

Coder/Specialty Medical Bill Revieweris responsible for reviewing, auditing, and data entry of medical bills for multiple states and lines of business within both Workers Compensation and Commercial Health arenas. This would include analysis for the fee schedule or usual and customary application, as well as PPO interface, while meeting contractual client requirements.

Essential Job Functions:

Responsible for auditing medical bills to ensure that they are appropriate and adhere to the State Fee Schedules, customer guidelines, and PPO discounts

Analysis and review of 1 or more assigned states having fee schedules

Utilize Fee Schedules, Online Documents, Client instructions, and other training material to properly review medical bills

Review medical bills for compensability and relatedness to injury

Reprice medical bills to Workers Compensation Fee Schedule and PPO Network

Research usual and customary/fee schedule applications and system interface as appropriate

Reviews specialized Medical Bills, which include hospital, surgery, and high-level physician bills for workers' compensation and non-workers' compensation claims, and may include hospital bills, auto liability, and usual and customary reimbursement

Determines the appropriateness of a final reimbursement outcome by making the distinction between and knowing when to apply either Fee Schedule reduction, PPO reduction, Usual and Customary reduction, or Medicare reduction

Communicates and defends to providers and clients the basis for the methodology used to accomplish the reduction of charges

Analyzes and reviews high-level office visits, reports, and record reviews

Interprets hospital review guidelines for both inpatient and outpatient claims

Knowledge of medical terminology, workers compensation billing guidelines, and fee schedules, including CPT/ICD/HCPS coding, and knowledge of UB04 and CMS 1500 form @types preferred

Responsible for producing a final review for the recommendation of payment to the client

Maintain productivity, as well as speed and level of accuracy, as determined by company standards

Requirements

Abilities and Competencies:

Current knowledge of utilization review processes and managed care

Knowledge of state-based fee schedules

Strong knowledge of Medical Terminology and CPT/ICD-9/ICD-10 coding

Ability to identify trends through analysis of practices to improve the overall utilization of resources and cost containment

Ability to communicate those trends found through analytical study using a variety of reporting mediums

Ability to work collaboratively and independently while meeting productivity standards

Ability to work in a high-production environment while meeting productivity and quality standards

Ability to represent Utilization Management in organizational committees, as assigned

Excellent relationship management skills

Demonstrated ability to problem-solve in complex situations

Ability to engage in abstract thought

Strong organizational and task prioritization skills

Strong analytical, numerical, and reasoning abilities

Well-developed interpersonal skills

Ability to establish credibility and be decisive - while also recognizing and supporting our organizations preferences and priorities

Results-oriented with the ability to balance other business considerations

Knowledgeable of multi-state workers compensation systems

Computer literacy on Microsoft Office products and database programs

Ability to construct grammatically correct reports using standard medical terminology

Must have a track record of producing highly accurate work, demonstrating attention to detail

Education and Experience:

High School Diploma or equivalent

AAPC Coding Certification is required (CPC required, CIC preferred)

ICD-9, ICD-10, PCS/HCPS/CPT, MS-DRG, and Geographical codes, and NCQA regulatory compliance guidelines

Must have a consistent coding rate at the 95th percentile or higher

RAC review and auditing

Proficiency as a Specialty Medical Bill Reviewer with two or more years of previous experience in medical bill review (workers compensation is a plus)

Driving Essential:No

Certifications/Licenses:AAPC Coding Certification (CPC required, CIC preferred)

Position Demands:

This position requires sitting, bending, stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 10 lbs. Ability to learn technical material. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office equipment such as a calculator, copy machine, printer, etc. Some travel may be required.

Equal Employment Opportunity (Our EEO Statement):

The Company is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The Company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment.

We are committed to creating an inclusive environment for all team members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.

Disclaimer:

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 to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All team members may be required to perform duties ou

Nexus Enterprises

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