Bill Review Specialist Lead

Paradigm • Tampa, FL

1d • Hybrid

About The Position

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm’s business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs. We’re proud to be recognized—again! For the fourth year in a row, we’ve been certified by Great Place to Work®, and for the third consecutive year, we’ve earned a spot on Fortune's Best Workplaces in Health Care™ list. These honors reflect our unwavering commitment to fostering a positive, inclusive, and employee-centric culture where people thrive. Watch this short video for a brief introduction to Paradigm. Paradigm is seeking a full-time, benefitted Bill Review Specialist Lead for a hybrid position in our Tampa, FL, office. The Lead Specialist provides senior-level support for provider bills (claims) and appeals research and issue resolution. This role serves as a subject matter expert health care bill payment operations, leading the most complex and high-priority projects. Responsibilities include advanced root-cause analysis, regulatory and contract interpretation, project management, and strategic coordination across multiple departments to resolve systemic provider bills (claims), appeals, and billing issues. The Lead Specialist delivers thought leadership, develops remediation strategies, and ensures timely, accurate project execution while driving continuous improvements in claims performance and compliance. Additionally, the Lead Specialist acts as a key liaison between departments to communicate findings and resolution plans effectively.

Requirements

• Education – High School Diploma or equivalent required.
• Experience - 5+ years in worker’s comp and/or in medical claims processing, research, or a related field (Managed Care Organization – Medicaid, Medicare, Commercial).
• Project management.
• Intermediate computer experience using Microsoft Word, Excel & Outlook required
• Excellent organizational skills.
• Excellent oral communication skills and phone presence.
• Ability to effectively tailor complex information for diverse audiences, including providers and executive leadership
• Proven ability to manage multiple projects, prioritize tasks, and meet tight deadlines in a fast-paced environment.

Nice To Haves

• Bachelor’s Degree or equivalent combination of education and experience: Preferred.
• Any combination of education, certification (CPC, CRC, etc.) experience and/or knowledge that demonstrate the ability to perform the functions of the position will be accepted.
• Knowledge of Worker’s Comp; Healthcare billing; ICD-9 or ICD-10; CPT; RVS; U&C; Fee Schedule; HCPCS & other coding schemes preferred.

Responsibilities

• Receive, research, coordinate, and resolve incoming bills, appeals, or client inquiries, payment questions, and issues with internal team members, providers, or clients, as appropriate.
• Assist in reducing rework by identifying and remediating billing, appeals, and client processing issues.
• Use advanced analytical skills to conduct research and analysis for issues, requests, and inquiries on high priority claims/appeals projects.
• Evaluate processed provider payments data using standard principles and applicable state-specific policies or agreements (e.g., Single Case Agreements) to identify reimbursement or billing processing errors.
• Customize existing reports or available data to meet the needs of claims projects.
• Act as a senior provider reimbursement subject matter expert, advising on complex billing issues and ensuring compliance with regulatory and contractual requirements.
• Lead and manage major provider payments research projects of considerable complexity, initiated through provider or client inquiries or internal requests.
• Conduct advanced root-cause analysis to identify and resolve systemic bill processing errors, collaborating with multiple departments to define and implement long-term solutions.
• Interpret regulatory and contractual requirements to ensure compliance with provider payments (claims) or appeals adjudication and remediation processes.
• Develop, track, and/or monitor remediation plans, ensuring provider reimbursements (claims)/appeals reprocessing projects or inquiries are completed accurately and on time.
• Conduct periodic audits of provider payments and appeals processed by the team to ensure accuracy, compliance, and proper reimbursement, while maintaining a collaborative approach.
• Proactively identify and recommend updates to policies, SOPs, and job aids to improve claims quality and efficiency.
• Collaborate with internal stakeholders and leadership to define provider reimbursement and appeals requirements and ensure alignment with organizational goals.
• Assist in processing appeals and reconsiderations.

Benefits

• Health and wellness– We want our people to be and stay healthy, so we offer PPO, HDHP, and HMO health insurance options with Cigna and Kaiser (CA employees only).
• Financial incentives – Paradigm’s financial benefits help prepare you for the future: competitive salaries, 401(k) matching contributions, employer-paid life and disability insurance, flexible spending and commuter accounts, and employer-matched HSA contributions.
• Vacation - We believe strongly that work-life balance is good for you and for our company. Our paid time off and personal holiday programs give you the flexibility you need to live your life to the fullest.
• Volunteer time– We want our employees to engage with and give back to their communities in meaningful ways. Full and part-time employees receive one paid day per calendar year.
• Learning and development: One of Paradigm’s core values is expertise, so we encourage our employees to continually learn and grow. We support this in a variety of ways, including our new Learning Excellence at Paradigm (LEAP) program.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 251-500 employees