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

Requirements

• 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