Medical Fee Examiner

State of North Carolina • Wake County, NC

1d • Hybrid

About The Position

The North Carolina Industrial Commission is vested as a court of exclusive and original jurisdiction by the General Assembly to adjudicate and administer the North Carolina Workers' Compensation Act. The Industrial Commission processes over 65,000 workers' compensation injury reports and claims filed annually under the Act. This responsibility includes overseeing and providing for the trial of contested cases as well as administering non-contested cases. Workers who are injured by accident on the job or who contract an occupational disease receive disability and medical benefits as ordered by the Industrial Commission. The Industrial Commission is also a court of original jurisdiction for litigating tort claims against the State under the North Carolina State Tort Claims Act. Additionally, the General Assembly has mandated the Industrial Commission to provide an adjudicated process for Childhood Vaccine-Related Injury claims and Compensation to Persons Erroneously Convicted of Felonies. It acts as a court of exclusive and final jurisdiction for death claims made by families of law enforcement officers, fire fighters, rescue squad workers and civil air patrol members arising under the Public Safety Employees' Death Benefits Act. Each of these adjudicatory systems requires administration of contested and uncontested claims, review of agreements, and supervision of payment of benefits. This position currently qualifies for a hybrid telework option with routine office and remote workdays. The posting will close at 11:59 p.m. the night before the closing date. The Medical Fees Section of the North Carolina Industrial Commission is responsible for reviewing and processing bills for medical services provided in a workers’ compensation claim when a party needs assistance applying the Commission’s Medical Fee Schedule. The Medical Fees Section also answers various medical bill and fee inquiries and is responsible for updating and maintaining the Industrial Commission’s Medical Fee Schedule. The Medical Fee Examiner also administers the informal phase of the Medical Provider Fee Dispute procedure to assist providers and parties with resolving medical fee disputes without litigation.

Requirements

• High school or General Educational Development diploma and four years of experience in a hospital, clinic, insurance company, or private organization involved in determining charges for professional medical services or hospitalization; or Graduation from a state accredited nursing program, one year of general nursing experience, and one year of experience in determining charges for professional medical services or hospitalization; or an equivalent combination of education and experience.
• Experience with Medicare reimbursement methodologies.
• Demonstrated expertise in medical terminology, clinical and surgical procedures, and medical coding, applying this knowledge to accurately calculate reimbursement according to Medicare and other fee schedules.
• Demonstrated ability to input data and draft business correspondence with accuracy and attention to detail, including modifying correspondence or report templates where necessary.
• Demonstrated experience reviewing and processing information to determine conclusions, actions, or compliance with applicable laws, rules, or regulations.
• Demonstrated experience independently responding to inquiries and coordinating a variety of resources in acquiring and disseminating information.
• Demonstrated experience managing a large number of pending items and assisting in their timely completion.

Responsibilities

• Assist parties with the application of the Commission’s Medical Fee Schedule to medical bills in workers’ compensation claims by repricing the bill upon request or advising parties via telephone or email; In some cases, this will include reviewing the draft repricing prepared by a processing assistant
• Update and maintain the Medical Fee Schedule annually and as needed in conjunction with the Executive Secretary and the Commission’s Medical Fee Schedule vendor
• Issue letters to parties as needed regarding a variety of medical bill-related issues
• Advise on medical bill processing or coding issues and other questions from the public via telephone and email
• Administer the procedures of the informal phase of the Health Care Provider Fee Dispute Procedure (Rule 11 NCAC 23A .0614), including processing fee dispute requests, repricing related bills, contacting the parties for more information, requesting a response from the payor, conducting telephone conferences to help resolve the disputes, and creating a summary of the efforts to resolve the dispute if needed for the health care provider to request to intervene in the claim
• Maintain statistics on all work of the unit
• Assist with other duties within the Medical Fees Section and Executive Secretary’s Office as needed

Benefits

• 12 Annual paid Holidays
• North Carolina State Health Plan administered by AETNA
• Supplemental Benefits including: Flexible Spending Accounts, Accident Insurance, Cancer & Specified Disease, Critical Illness, Dental and Vision
• NC State Retirement (TSERS)
• WeSave Employee Discounts

What This Job Offers

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