Sr Medical Review Specialist

Zenith Insurance Company•Los Angeles, CA

14d

About The Position

Under limited supervision, analyzes and audits medical bills from providers to determine appropriate reimbursement. Audits, analyzes, arranges and revises submitted information to determine reimbursement. Tracks issues and trends and makes recommendations for process documentation and technical improvements. Demonstrates an expert ability to provide or obtain complex information. As a subject matter expert, they coordinate and lead training on specialty topics.

Requirements

High School Diploma or equivalent combination of education and experience required
3+ years' experience reviewing progressively complex medical bills and records including multi-state and multi-jurisdictional required
Thorough and advanced understanding of Workers’ Compensation claim billing process knowledge required
Must demonstrate an expert ability to communicate proficiently using industry and regulatory language
Must be efficient in at least one advanced coding pend, negotiation queue, or other advanced specialty
Strong verbal and written communication skills
Strong prioritization and time management skills
Flexible and adaptable to a growing changing environment

Nice To Haves

Bachelor’s Degree or equivalent combination of education and experience preferred

Responsibilities

Reviews and audits medical bills and re-evaluations from all states and jurisdictions to ensure accuracy in coding.
Conducts timely and accurate processing of provider reconsiderations and/or resubmissions as assigned.
May negotiate reimbursement on medical bills directly with providers and billing office personnel to settle open, unresolved medical services.
Manages an assigned caseload to resolve outstanding disputes and liens from medical providers and other vendors for the purpose of cost savings and reductions for the company. Collects appropriate supporting documentation and works with or under the direction of a supervisor or manager to reach resolution.
Identifies and seeks solutions to processes and/or systems issues impacting the team/department.
Research billing issues, state regulations, Medicare billing rules and other coding entities. Collects documentation and submits for investigation per the Compass ticket process.
May develop or work with management to develop appropriate metrics to monitor success of new solutions.
Considers the impact of changes to workflows and communicates to supervisor and/or manager if changes or allocation adjustments are necessary.
Leads initiatives to achieve adjustments to workflows as needed to improve process efficiencies and reduce overall costs.
Serves as technical expert and main resource to Claims Examiners and Provider Dispute Resolution staff on state disputes or provider complaints. Researches and develops defensible responses to be submitted to the state.
May also service as a resource to Attorneys on claims where the case in chief is active by addressing provider dispute issues to minimize exposure.
Assists Bill Review Attorney and Compliance Specialist in gathering, reviewing, and summarizing documentation for defending appeals, petitions, and other disputes.
May assist in representing the company before regulators.
Demonstrates an expert ability to collaborate with vendors and providers to ensure they complete their contracted services and assists in monitoring processes and outcomes of vendors as needed/delegated.
Participates in decisions regarding priorities, scope, and timeline for assigned projects.
Identifies, documents, and collaborates with management regarding trends in provider and billing practices.
Identifies changes needed in decision rules and communicates with supervisor and/or manager to improve efficiency of workflow.
Mentors and assists with training of advancing Analysts in areas of increased complexity. May include preparation and/or development of training materials.
Responsible for review of higher level, technical Workers’ Compensation bills, managing a diverse assignment that includes all types of medical and medical-legal services; including initial billing submissions, and re-evaluations/reconsiderations from single or multi- state jurisdictions, according to state fee schedules, guidelines, PPO network pricing and formal policies and procedures.
Collaborate with Business Technical Team, Leads & Supervisors to propose, pilot and/or assist with workflow improvements.
Work productively and harmoniously with others on a consistent basis.
Respond positively to direction and feedback on performance.
Apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
Consistently maintain professional and appropriate demeanor.
Performs other job related duties as assigned.