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Medical Bill Review Specialist I in Lansing, MI at AF Group

Date Posted: 5/3/2018

Job Snapshot

Job Description

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 including outpatient hospital and single surgeries by utilizing our Medical bill review 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 generating assigned medical bills to determine compliance with business rules, client specific requirements and multiple state rules, regulations and guidelines.

PRIMARY RESPONSIBILITIES: Medical Bill Review Specialist I:
  • Ensures provider compliance with the Workers Compensation Health Care Services Rules and Fee Schedule.
  • Provides QA for basic bills for adjudication within StrataWare.
  • Reviews, analyzes, adjusts and releases bills, including duplicates.
  • Reviews basic hospital and surgery billings.
  • Refers to reference library of fee schedules, CPT, ICD-9/10, 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 Bill Review Analyst and/or MBR Management.
  • Provides a high level of customer service for all business partners and customers.
  • Identifies problems, provides solutions and resolves promptly; escalating more complex problems appropriately.
  • Manages confidential client information with discretion and good judgment in accordance with department and company guidelines.

    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.
  • Evaluates medical bills and corresponding EOR's for accuracy and compliance with state mandated fee schedule(s) and our business rules and guidelines.
  • Reviews hospital and surgery billings.
  • Reviews, analyzes, adjusts and releases queued bills to ensure timely payments.
  • Process reconsiderations, as needed.
  • Identifies system and/or bill review processing issues and reports findings to MBR Management.
  • Demonstrates a dependable work ethic.
  • Collaborates with MBR Management to develop skills and knowledge.
  • Provides training support for Bill Review Specialist I, as a mentor.
  • Responds to written or verbal inquiries relating to our bill review analysis. Analyzes problems using problem solving methodology skills to determine root cause; communicates and implements solutions.

    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.





    EMPLOYMENT QUALIFICATIONS:



    A. EDUCATION REQUIRED: (Brief paragraph detailing the minimum education required, including certifications) Do not state preferred qualifications.

    High School Diploma or G.E.D.

    EXPERIENCE REQUIRED: (Minimum experience required to perform this job) Do not state preferred experience. Relevant experience must provide the necessary skills, knowledge and abilities provided in Section C of this description.

    Medical Bill Review Specialist I

    Minimum of one-year general office experience

    OR

    One year of other relevant experience that provides the necessary skills, knowledge and abilities.

    OR

    With degree or certification in medical coding no experience required.

    Medical Bill Review Specialist II

    One year as a Medical Bill Review Specialist I, including 2 or more state medical payment methodologies.

    OR

    Two years working knowledge of bill processing with 2 or more state medical payment methodologies.

    OR

    Two years experience in an insurance organization including one year in workers

    compensation.

    AND

    Demonstrated technical knowledge in medical bill review, OR other relevant experience, which provides necessary skills, knowledge and abilities.

    C.

    SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

    (Brief bullet points detailing the skills, knowledge, and abilities required for this job. SKA's should tie back to the primary responsibilities required)

    Medical Bill Review Specialist I:


  • Basic knowledge of medical terminology and CPT/ICD-9/10 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/Knowledge/Abilities of Medical Bill Review Specialist II:


  • Knowledge of various state workers' compensation medical payment methodologies.
  • Excellent oral, written communication and customer service skills.
  • Knowledge of Workers Compensation medical fee schedules, Medical guidelines, medical terminology and CPT/ICD-9/10.
  • Demonstrated attention to detail.
  • Basic knowledge of the Workers Compensation Act and Claims process, including medical reserving procedure.

    D. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: (Briefly detail the preferred education, experience, skills, knowledge and/or abilities desired to perform this job, including certifications). These are in addition to the required qualifications - Do not state required qualifications.


  • Additional training or coursework in a medical field preferred.
  • Medical Billing/Coding diploma preferred.



    WORKING CONDITIONS:



    Work is performed in an office setting with no unusual hazards.

    REQUIRED TESTING: (For HR use only)

    Medical Bill Review Specialist I:

    Basic Windows, Reading Comprehension, Alpha Numeric, 10 Key, and Math

    Medical Bill Review Specialist II:

    Basic Windows, Reading Comprehension, 10 Key, Math, Alpha Numeric

    Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
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