Job Description

Job Description

Job Description

Description:

Under moderate supervision, responsible for reviewing, auditing and data-entry of medical bills for multiple states and lines of business within both Worker’s Compensation and Commercial Health arenas. This would include analyzation for 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 includes hospital, surgery and high-level physician bills for workers compensation and non-workers compensation claims and may include hospital bills, auto liability, 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 recommendation of payment to the client
• Maintain productivity as well as peed and level of accuracy as determined by company standards

Knowledge and Abilities Requirements:

• 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, including a high degree of professional demeanor and non-aggressive assertiveness
• Demonstrated ability to problem solve complex, multifaceted situations
• Ability to engage easily in abstract thought
• Strong organizational and task prioritization skills
• Strong analytical, numerical and reasoning abilities
• Well-developed interpersonal skills. Ability to get along with diverse personalities. Tactful, mature.
• Ability to establish credibility and be decisive – but able to recognize and support the organization’s 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 data base programs
• Ability to construct grammatically correct reports using standard medical terminology
• Must have a track record of producing work that is highly accurate, demonstrating attention to detail, and reflecting well on the organization.

Education and Experience:

• High School Diploma or equivalent
• AAPC Coding Certification (CPC required, CIC preferred)
• ICD-9, ICD-10, PCS/HCPS/CPT, MS-DRG, and Geographical codes and NCQA regulatory compliance guidelines.
• 95th percentile
• RAC review and auditing
• Proficiency as a Specialty Medical Bill Reviewer with two or more years previous experience in medical bill review (workers’ compensation is a plus)

Driving Essential: Yes
Position Demands: This position requires sitting, bending, stooping for up to 8 hours per day at a computer. 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.
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 Nexus employees may be required to perform duties outside of their normal responsibilities from time to time, as needed.

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