Medical Bill Rev Specialist I/II

Blue Cross Blue Shield of Michigan•Lansing, MI

About The Position

This role involves analyzing medical bills for multi-state Workers Compensation claims to determine the appropriateness of services billed and ensure compliance with various regulations and client-specific requirements. The Medical Bill Review Specialist I focuses on simpler billings and basic QA, while the Medical Bill Review Specialist II handles more complex cases, including modifiers, anesthesia, psychiatric services, outpatient hospital, and multiple surgeries.

Requirements

High School Diploma or G.E.D.
Minimum of two years of experience in a medical billing and/or coding position or similar relevant experience (for Specialist I).
Degree/Certificate of completion in Medical Coding or Billing (for Specialist II).
Minimum of one year as a Medical Bill Review Specialist I OR Minimum of two years demonstrated experience in workers compensation medical bill review analysis/pricing (for Specialist II).
Basic knowledge of medical terminology, anatomy, and CPT/ICD-CM codes, & medical fee schedule (for Specialist I).
Basic knowledge of computers and ability to enter alpha/numeric data accurately (for Specialist I).
Math skills with the ability to use a ten-key calculator (for Specialist I).
Effective oral, written and communication skills.
Ability to consistently meet or exceed daily production and quality standards for this position.
Ability to use reference manuals and apply information to medical claims.
Excellent organizational skills and ability to prioritize work.
Ability to work with minimal direction (for Specialist I).
Knowledge of various state workers’ compensation medical payment methodologies (for Specialist II).
Demonstrated attention to detail (for Specialist II).

Responsibilities

Analyzes bills for multi-state Workers Compensation medical claims to determine appropriateness of services billed.
Analyzes simple billings using Medical Bill Review (MBR) software to determine appropriateness of codes.
Makes bill review processing determinations according to rules, regulations, and/or third-party partners.
Performs technical review of more complex medical bills, including modifiers, anesthesia, & psychiatric.
Analyzes billings including outpatient hospital and multiple surgeries using MBR software to determine appropriateness of codes and excessive charges.
Analyzes assigned medical bills to determine compliance with business rules, client specific requirements and multiple state rules, regulations and guidelines.
Provides QA for basic bills for adjudication within Bill Review system.
Reviews, analyzes, adjusts and releases basic bills, including duplicates.
Refers to reference library of fee schedules, CPT, ICD-CM, HCPCS and other industry publications to support findings.
Assists all bill review teams as assigned with current work volumes or backlogs to ensure timely payments.
Identifies system and/or reports bill review issues and findings to MBR Leadership.
Provides a high level of customer service for all business partners and customers.
Reviews state reporting criteria as related to bill processing and outlined in state guidelines.
Manages confidential client information with discretion and good judgment in accordance with department and company guidelines.
Demonstrates a dependable work ethic.
Reviews hospital and surgery billings.
Reviews, analyzes, adjusts and releases queued bills to ensure timely payments.
Ensures provider compliance with the Workers Compensation Health Care Services Rules and Fee Schedule.
Processes reconsiderations where no previous payment has been issued.