Casualty Bill Review Specialist

Brighton Health Plan Solutions, LLC•Chapel Hill, NC

7d•Remote

About The Position

The Casualty Bill Review Specialist is responsible for ensuring accurate, compliant, and efficient medical bill review within the New York workers’ compensation and casualty environment. This role serves as a subject matter expert (SME) in New York and other state regulations, partnering closely with Network, Operations, and cross-functional teams to ensure proper configuration of bill review processes, rules, workflows, and pricing implementation. The Specialist is also responsible for training interdepartmental staff on applicable rules, policies, procedures, and regulatory requirements. This is a remote role.

Requirements

At least 5 years of demonstrated expertise of New York MTGs
Expertise in NY fee schedules and reimbursement methodologies
Knowledge of CMS-1500 EDI billing
Understanding of medical narratives and attachments
Experience with WCB dispute processes
Strong knowledge of CPT, HCPCS, ICD-10 coding
Familiarity with Medical Necessity forms and Authorizations
Understanding of NY billing regulations and PAR processes
Ability to review bills for compliance
Knowledge of DME, Home Health, and Ancillary reimbursement
Understanding of prompt payment requirements

Responsibilities

Review medical bills for accuracy, coding validity, and compliance with New York Workers’ Compensation Board (WCB) regulations.
Apply New York Medical Treatment Guidelines (MTGs).
Ensure proper application of New York fee schedules and reimbursement methodologies.
Evaluate medical narratives and attachments.
Ensure compliance with prompt payment requirements.
Configure and maintain bill review rules and workflows.
Partner with Network and Operations for pricing implementation.
Monitor system outputs and recommend improvements.
Collaborate with Network, Operations, IT, and vendors.
Ensure alignment of bill review strategies and processes.
Serve as SME for New York bill review.
Develop and deliver training programs.
Create job aids and documentation.
Collaborate with team members on denials, reconsiderations, and dispute processes.
Ensure WCB compliance and audit readiness.