High Dollar Review Specialist

Brighton Health Plan Solutions, LLC • Chapel Hill, NC

40d

About The Position

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high dollar claims for appropriate and accurate billing, pricing and adjudication. This individual will play a key in the Quality Department and interact with many internal and external stakeholders.

Requirements

• Significant experience in dealing with facility-based billing.
• Experience with physician/ancillary billings.
• Expertise in DRG Groupers.
• Candidate should have at least 3-5 years or more of coding and claims examination experience.
• Working knowledge of Drug Reimbursement methodologies including AWP and ability to calculate J code reimbursements.
• Familiarity with hospital billing systems and methodologies and healthcare terminology.
• Impeccable follow up, organization, and time management skills.
• Work well with all levels of management internally and externally also with the ability to work independently.
• Confident, patient, work well with other, not afraid to ask question, open to learning.
• Great communication skills (both written and oral).

Responsibilities

• Review high dollar claims to ensure claim was priced and billed correctly including implant and supply charges, observation room charges, units billed for drugs and procedures.
• Review DRG for accuracy as compared to billed procedures, diagnosis/condition, age, etc.
• Develop reporting mechanism to track pertinent claims information related to high dollar claims.
• Collaborate review efforts with CMO, Legal and other departments as needed.
• Coordinate efforts with external vendors as required.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed