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Role Description

This position holds accountability for accurate and timely review, processing and payment of bills to include pre-coding accuracy and adjudication of medical bills.

• Examines and adjudicates bills for all provider types, product lines, bill types and lines of business from start to finish
• Evaluates medical documentation, diagnosis codes, and treatment context to determine relatedness of services to a compensable injury
• Maintains knowledge of industry standard medical coding initiatives and state specific fee schedules and coding guidelines such as Medicare reimbursement methodology, NCCI edits, MUEs, Level of Service reviews and outlier charges
• Meets or exceeds department contractual and/or industry standards for accuracy and turnaround time
• Maintains an understanding of all variations of Workers’ Compensation State rules and regulations with the ability to navigate and interpret various types of fee schedules
• Maintains comprehensive knowledge of all available non-fee schedule re-pricing opportunities (e.g. PPOs, direct contracts, Fair Market Pricing etc.) and ensures application as part of the adjudication process
• Monitors itemized billings for excessive charges, duplications, and appropriate medical bills coding
• Reviews/processes appeals
• Initiates refund requests and assists in the recoupment process as needed
• Assists in Contract Recoveries, as needed
• Assists in the preparation of bills research reports
• Provides customer service to render efficient customer satisfaction, including timely response and resolution to customer issues, complaints, questions and requests

Qualifications

• Education - AA Degree or equivalent bill review experience
• Experience – 3+ years of medical coding or bill review experience
• Intermediate computer experience using MS Word, MS Excel & Outlook required
• Typing speed of 60 WPM on data entry
• Excellent organizational skills
• Knowledge of ICD-10; CPT; Revenue Code; RVS; U&C Fee Schedule; RBRVS; DRG; HCPCS & other coding schemes
• Excellent oral communication skills and phone presence
• Ability to effectively present information to providers as well as to employees of the organization
• Ability to define problems, collect data, establish facts, and draw valid conclusions
• Ability to interpret a variety of instructions and deal with abstract and concrete variables

Benefits

• Health and wellness – PPO, HDHP, and HMO health insurance options with Cigna and Kaiser (CA employees only)
• Financial incentives – competitive salaries, 401(k) matching contributions, employer-paid life and disability insurance, flexible spending and commuter accounts, and employer-matched HSA contributions
• Vacation - paid time off and personal holiday programs for work-life balance
• Volunteer time – one paid day per calendar year for community engagement
• Learning and development – support for continual learning and growth through the Learning Excellence at Paradigm (LEAP) program