Medical Bill Rev Specialist I​/II

View Summary

Company: AF Group

Location:

Lansing, USA

Level: Non-Manager

Compensation:
Competitive Compensation and Benefits Package

Job Family:
Claims Processing

Industry: Insurance Services

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 (M ) 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, and psychiatric. Responsible for analyzing billings including outpatient hospital and multiple surgeries by utilizing our Medical Bill Review (M ) 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.

• 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.
• Assists 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 M  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.
• Processes reconsiderations where no previous payment has been issued.

• High School Diploma or G.E.D. is required.
• For Specialist I:
  Minimum of two years of experience in a medical billing and/or coding position or similar relevant experience.
• For Specialist II:
  Degree/Certificate of completion in Medical Coding or Billing is required. Minimum of one year as a Medical Bill Review Specialist I.
• For Specialist II:
  Minimum of two years of demonstrated experience in workers' compensation medical bill review analysis/pricing.

Essential knowledge and skills

• Basic knowledge of medical terminology, anatomy, CPT/ICD-CM codes, and 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.
• Knowledge of various state workers’ compensation medical payment methodologies.
• Demonstrated attention to detail.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.