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Provider Relations Specialist in Lansing, MI at AF Group

Date Posted: 10/1/2018

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.


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