Bill Review Specialist

Ethos Risk Services • Lake Forest, CA

4d • $22 - $28 • Hybrid

About The Position

Our dynamic Bill Review team is seeking a full-time Bill Review Specialist to review, audit, and process workers' compensation medical bills while ensuring compliance with state fee schedules, regulatory requirements, and client-specific guidelines. The ideal candidate is analytical, organized, and committed to delivering accurate, high-quality work in a fast-paced environment.

Requirements

• High school diploma or equivalent (required).
• Minimum of 3 to 5 years of workers' compensation bill review experience, reviewing and adjudicating medical bills using state fee schedules, PPO contracts, reimbursement methodologies, client guidelines, and applicable workers' compensation regulations. (required).
• Knowledge of CPT, ICD-10, HCPCS (required).
• Experience in billing accuracy, reimbursement eligibility, code relationships, bundled services, modifier usage, and reimbursement calculations while applying regulatory and client-specific guidelines (required).

Nice To Haves

• Associate's degree or higher is preferred.
• Experience using Conduent Strataware software (preferred).
• Experience applying multi-state workers' compensation fee schedules, reimbursement methodologies, payment policies, and jurisdiction-specific regulations (preferred).
• Experience researching complex reimbursement issues, fee schedules, and regulatory guidance to support accurate and defensible payment determinations (preferred).
• Experience managing provider appeals, reconsiderations, and billing disputes, including communicating reimbursement methodologies and payment decisions (preferred).
• Experience reviewing complex medical bills, including hospital, ASC, DME, transportation, home health, dental, and other specialty bill types involving advanced reimbursement analysis (preferred).

Responsibilities

• Review and adjudicate hospital, ambulatory surgery center (ASC), durable medical equipment (DME), pharmacy, transportation, home health, and other specialty medical bills for reimbursement accuracy and compliance.
• Investigate provider appeals, reconsiderations, and billing disputes by interpreting applicable fee schedules, reimbursement methodologies, regulations, and client guidelines.
• Draft clear, professional written correspondence explaining payment decisions and reimbursement methodologies to providers.
• Respond to provider inquiries via phone and written correspondence regarding reimbursement decisions, payment methodologies, and billing questions.
• Partner with the Account Management team and other internal stakeholders to resolve billing issues, answer client questions, and support operational objectives.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED