Bill Quality Specialist
AF Group

Job Info

SUMMARY:

Perform audits for quality purposes enterprise wide to ensure appropriate payments and provide operational consistency and compliance with business rules. Primary focus includes, but not limited to the medical bill processing function and state reporting function as it relates to audit. Serves as a resource regarding workers compensation medical bill review auditing as well as statutory, regulatory, and jurisdictional compliance. This position requires knowledge in all facets of workers' compensation medical bill review.

PRIMARY RESPONSIBILITIES:

• Provide accurate and timely bill audits for all brands and vendors as outlined in the MBR quality program.

• Conduct accurate and timely audits of our vendor partners and medical bill data reported to states by medical bill vendor.

• Conduct accurate and timely audits of medical bill payments, over 50k, to maximize cost containment opportunities and compliance with statutory regulations.

• Responsible for collecting, analyzing and tracking of state penalties and making recommendations for payment or to challenge a penalty. Articulate feedback in a positive, meaningful manner to facilitate continuous improvement.

• Compiles, creates, prepares, and reviews for accuracy, information and reports as requested or scheduled. This includes analyzing trends and data, creating reports and recommending best practice guidelines to be shared across the brands. Determines overall format for most efficient display of information.

• Collaborate with medical bill review management and stakeholders to ensure understanding, alignment and consistency in program and workflow performance.

• Coordinates regulatory changes and updates, assists in the monitoring of policies, practices and procedures and works closely with all bill review managers and stakeholders to appropriately translate the updates to the end user.

• Partner with training, medical bill review management and medical bill stakeholders to identify training needs based on quality assessment results. Support development and delivery of training as necessary/assigned. May also be a resource for employee training.

• Perform audits of training initiatives to provide feedback to training on adoption of the training material.

• Provide evaluation and input regarding effectiveness of programs and projects.

• May attend training sessions to understand changes to processes, regulations and workflows.

• Serves as an enterprise resource regarding medical bill review guidelines and state compliance regulations.

• Participates in annual review of MBR function and results. Provides materials as requested in support of this review.

• Drafts agendas, maintains meeting log, and attends monthly quality meetings with our external medical payment partners to address quality issues and avenues for resolution.

• Participates in review of process changes and/or vendor change/review with a clear focus on the potential impact to medical bill review quality, accuracy and results.

• Participates in complex projects as assigned (i.e. may conduct audits such as, but not limited to medical, expense, fine/penalties, refunds, state specific analysis).

• Maintains confidentiality of all information processed.

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

A. EDUCATION REQUIRED:

Associate's Degree in insurance, business, or a related field. College courses in medical billing and coding required. Combination of relevant education and work experience may be considered in lieu of a degree.

B. EXPERIENCE REQUIRED:

Three years as a Medical Bill Review Specialist III, Medical Bill Review Analyst or Provider Relations or combination of these positions, and working knowledge of three or more state payment methods.

OR

Five or more years in medical bill review and/or evaluating complex services (i.e. med-legal, Consults, multiple surgical or hospital), including two years previous medical bill review experience in an insurance industry, preferably Workers Compensation which provides working knowledge of payments in three or more payment methodologies.

C. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Extensive knowledge of workers compensation insurance and the medical bill review process which includes fee schedule(s), compliance regulations, Medicare guidelines, CPT, ICD-9, and HCPCS coding and other healthcare programs.

• Ability to analyze complex billings including hospital, surgery center and surgeries by utilizing medical bill review software to determine appropriateness of codes, excessive charges, and unbundling of codes.

• Ability to review, evaluate, and determine appropriateness of reconsiderations, negotiated bills, and dispute resolutions.

• Knowledge of Workers Compensation methodologies for multiple states.

• Knowledge of relevant guidelines and regulations for multiple states related to insurance.

• Ability to read, analyze and interpret governmental regulations.

• Ability to understand and implement audit processes and procedures for state specific or regional practices and regulations.

• Ability to read, analyze and interpret policy documents, technical, legal and financial information, and procedures manuals.

• Working knowledge of medical terminology, anatomy, and billing codes.

• Ability to thoroughly review and analyze medical records and operative reports as they related to procedures billed.

• Excellent oral and written communication skills.

• Excellent analytical skills to identify opportunities for improvement and recommend solutions.

• Ability to comprehend consequences of various situations to make appropriate individuals aware to facilitate decision making.

• Strong analytical and problem solving skills.

• Ability to manage multiple projects and meet necessary deadlines.

• Knowledge of computers, word processing and spreadsheet software, ability to enter accurately 50 WPM.

• Ability to perform mathematical calculations.

• Ability to proofread documents for accuracy of spelling, grammar, punctuation and format.

• Ability to maintain confidentiality.

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards. Minimal travel.

REQUIRED TESTING:

Reading Comprehension, Math, Typing 50wpm, Proofreading, Intermediate Word, Intermediate Windows and Intermediate Excel