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Provider Relations Specialist in Lansing, MI at AF Group

Date Posted: 6/13/2018

Job Snapshot

Job Description

Responsible for addressing complex and high priority bill inquiries from providers, agents, and clients. Responsible for providing quality, consistent and accurate payment information to internal and external customers. Also responsible for analyzing billings including outpatient hospital and multiple surgeries by utilizing our Medical Bill Review (MBR) software and reference library to determine appropriateness of codes and excessive charges. Responsible for making coding determinations according to state rules and regulations.

  • Responsible for performing technical review of more complex medical bills, including but not limited to modifiers, anesthesia, & psychiatric.
  • Responsible for generating assigned medical bills to determine compliance with business rules, client specific requirements and state specific fee schedules, rules, regulations and guidelines.
  • 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 inpatient hospital, outpatient hospital and multiple surgery billings.
  • Reviews, analyzes, adjusts and releases queued bills in an accurate and timely manner.
  • Refers to reference library of fee schedules, CPT, ICD-9 (10), HCPCS and other industry publications to support findings.
  • Process reconsiderations, as needed.
  • Identifies system and/or bill review processing issues and reports findings to Supervisor or Manager.
  • Provides high level of customer service for all business partners, internal or external customers thru telephonic, email, and fax.
  • Demonstrates a dependable work ethic.
  • Manages confidential client information with discretion and good judgment in accordance with department and company guidelines.
  • Collaborates with supervisor to develop skills and knowledge.
  • Identifies problems, provides solutions and resolves promptly; escalating more complex problems appropriately.
  • Responds to written or verbal provider inquiries relating to our bill review analysis. Analyzes problems using problem solving methodology skills to determine root cause; communicates and implements solutions.
  • Acts as a resource to MBR employees in regard to bill review questions and concerns.



    High School Diploma or G.E.D. Additional training or course work in a medical field required.


    Degree or Certification in Medical Coding


    One year as a Medical Bill Review Specialist II


    Three years experience in an insurance organization with demonstrated technical knowledge in medical bill review or other relevant experience, which provides necessary skills, knowledge and abilities. One year experience in Workers Compensation industry required. Previous experience in customer service required.


    With degree or certification in medical coding with one to two years customer service experience in a medical setting.


  • Ability to use independent discretion to make choices on proper reimbursement.
  • Basic knowledge of spreadsheet software.
  • Knowledge of computers.
  • Working knowledge, experience, and ability to process bills using state medical payment methodologies.
  • Ability to proofread documents for accuracy of spelling, grammar, punctuation and format.
  • Ability to perform mathematical calculations with the ability to use a ten-key pad with accuracy.
  • Ability to manage work with minimal direction.
  • Excellent oral, written communication and customer service skills.
  • Extensive knowledge of Workers Compensation multi state medical fee schedules, Medical guidelines, medical terminology and CPT/ICD-9/10.
  • Demonstrated attention to detail.
  • Basic knowledge of the Workers Compensation Act.
  • Ability to consistently meet or exceed daily production and quality standard for this position.


  • One year of previous telephonic experience.
  • Degree in medical coding.
  • Basic knowledge of Claims process including medical reserving procedure.


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


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

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