Bill Review Nurse Specialist - REMOTE! - LVN/LPN/RN

About the position Under the direction of the Bill Review Manager, the Bill Review Nurse Specialist is responsible for utilizing clinical acumen and medical review expertise related to reviewing workers’ compensation medical bills, including but not limited to: reviewing medical records, detailed/itemized statements and other documentation and applying medical necessity or payer guidelines to identify billed items and services that do not meet appropriate regulatory and compliance guidelines Position Specifics: Exempt-Full Time, Remote, Business Hours Monday through Friday

Responsibilities

• Accurately and appropriately analyze complex medical bills and make payment recommendations based on claim history, medical notes, usual and customary rates (UCR), statutory regulations including state laws and fee schedules, available MPN/PPO contracts, coding guidelines, client instructions, and company policies and procedures
• Research and apply applicable guidelines, and document clear and concise notes related to the recommendations along with related rationales
• Perform coding analysis. e.g. Medically Unlikely Edits (MUEs), Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT), Diagnosis Codes, etc.
• Engage with medical providers to negotiate medical services on behalf of our clients while creating long lasting relationships
• Communicate with medical providers to obtain needed information and resolve bill-specific issues
• Affidavits/Testify – Bill Review expert witness to provide expert testimony in legal cases involving medical billing disputes, or reasonableness of charges, particularly with insurance claims, workers’ compensation, personal injury, and medical malpractice.
• Review bills with missing Codes. Review corresponding medical documentation and provide appropriate billing.
• Medical Records – Able to review medical records
• Explanation of Review (EOR) – Provide EORs that include detailed sources to complete an analysis.
• Matching Diagnostic Codes with Bills – Able to match diagnostic codes to codes on a bill
• Respond to issues and drive problem resolution in a quick turn- around time
• Participate in ongoing training to enhance job skills and knowledge
• Maintain emphasis on privacy and confidentiality in all review interactions and completions
• Complete assigned cases accurately, meeting all regulatory and compliance timelines
• Continuous working knowledge of Ahshay and the BR system
• Support and assist all levels of the organization
• Other duties as assigned

Requirements

• US state licensed Nurse (RN, LPN, LVN)
• Experience in performing Bill audit reviews
• 3+ years of experience in complex Workers' Compensation Bill Review with customer service exposure (preferred)
• Knowledge of medical terminology and coding
• Ability to read, analyze, and interpret technical procedures, medical reports, state laws and fee schedules
• Excellent Written and Oral Communication Skills
• Excellent Interpersonal & Organization Skills
• Experience with computers and computer programs (MS Word, MS Excel, Email)
• Ability to work independently with minimal supervision
• Ability to meet deadlines in a high pressure, time sensitive environment
• The candidate must be able to sit the majority of the day.
• The candidate must be able to keyboard the majority of the day.
• Candidate must have manual dexterity.
• Candidate must be able to speak on the telephone intermittently throughout the day.
• Candidate must be able to read and write English fluently.
• Candidate must be able to provide and confirm safe home office environment.
• Home office must be HIPAA compliant.
• Requires DSL, fiber, or cable internet connection from home, 100 Mbps preferred or better.

Nice-to-haves

• CPC (Certified Professional Coding) coursework or certification a big plus
• 3+ years of experience in complex Workers' Compensation Bill Review with customer service exposure (preferred)

Benefits

• Medical, Dental, Vision Insurance
• 401K
• Paid Time Off
• Paid Holidays
• Monthly internet stipend

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