Under moderate supervision, this position is responsible for processing and auditing complex and/or high level medical bills in accordance with state Workers’ Compensation fee schedules rules and regulations, UCR, correct coding rules and PPO application/interface through the use of the Medata software. Bills will be processed in accordance with state mandated timeframes, client contractual requirements and established department production standards.
Duties / Responsibilities
- Enter and review workers compensation or no fault medical bills into the Medata system
- Analysis and review of 1 or more assigned states
- Perform technical or specialty review in one or more of the following areas:
- Complex Hospital, Surgery, Levels of Service, IME’s, etc
- Reconsideration Requests
- Quality Assurance Reviews
- Select proper PPO network based on client instructions
- Add or update Provider and Claim information as appropriate
- Utilize Fee Schedules, Online Documents, Client instructions and other training material to proper review medical bills
- Research usual and customary/fee schedule applications and system interface as appropriate
- Provide quality review on work as specified by Lead/Supervisor
- Perform quality assurance audits to ensure reviews are accurate
- Proactively identify system and/or bill review issues and provide feedback to supervisors or manager
- Other duties as determined by the Management
- High School diploma or equivalent – Associates Degree preferred.
- Ability to review higher complexity bills for facility and/or professional services.
- Knowledge for Worker’s Comp rules, regulations, and UCR and fee schedule rates.
- Ability to properly address provider requests to reconsider allowances
- Quality Review and PPO Network experience a plus
- Extensive knowledge of Workers’ Compensation medical fee schedules ( multi-state preferred ), state specific regulations, Medicare guidelines, ICD-9, CPT and HCPCs codes
- Proficiency with 10-key pad at 9000+ kph or equivalent bill processing rate
- Ability to work in a high production environment while meeting productivity and quality standards
- Proficiency with Microsoft Word and Excel
- Strong knowledge of Medical Terminology and CPT / ICD-9 coding
- Effective written and verbal communication skills