WC MED BILL REVIEW SPECIALIST

HEREFORD INSURANCE COMPANY•New York, NY

About The Position

Performs advanced technical review of Workers’ Compensation medical bills to ensure regulatory and coding compliance under NYS WCB mandates. This role applies advanced coding knowledge (CPC-level) to ensure the appropriateness of billed services, validating CARC and RARC denial code assignments, and ensuring all determinations align with statutory fee schedules and WCB electronic billing requirements. The role requires proficiency in EAPG and DRG methodologies, knowledge of multi-state compliance billing rules, and the ability to prepare detailed objections for disputed or high exposure bills. This job description in no way states or implies that these are the only duties to be performed. You will be expected to follow any other job-related instructions and to perform other job-related duties as requested by your supervisor.

Requirements

Working knowledge of the NYS Workers' Compensation Fee Schedule, Medical Treatment Guidelines, Department of Health APR-DRG and APGs Rules, Regulations and Reimbursement Components.
Knowledge of medical terminology, ICD9/10 and CPT coding and billing for Inpatient and Outpatient surgeries.
Coding and billing certification (CPC level.)
Ability to process bills according to quota with maximum accuracy. Ability to reference manual and apply information to medical claim.
Basic knowledge of computers and ability to enter alpha/numeric data accurately. Effective compensation skills and basic math skills
Excellent organizational skills and ability multitask and prioritize work.
Ability to work with minimal direction and demonstrate attention to detail.

Responsibilities

Ensures provider compliance with the NYS Workers’ Compensation Health Care Services Rules, Fee Schedule and e-billing processes in accordance with WCB mandates.
Demonstrates strong working knowledge of the NYS Workers’ Compensation Fee Schedule, AMA/CPT coding rules, modifiers, and NCCI policy guidelines as they apply to EAPG and DRG calculations.
Evaluates medical bills and corresponding EOBs for accuracy and compliance with applicable fee schedules, business rules, and state regulations; performs review of inpatient and outpatient hospital and surgical claims using EAPG and DRG methodologies.
Applies expertise understanding of CPT and HCPCS coding principles to verify appropriate modifier use, “BY Report” case documentation, and adherence to ground rules for provider surgery bill submissions.
Serve as liaison for all claims referred for outside medical review and petitions requiring referral to outside counsel for defense; maintain and track an organized log of cases.
Identifies and reports bill review issues or discrepancies to Bill Unit Manager or Nurse Case Manager.
Works closely with the Nurse Case Manager to review NY and out-of-state surgical claims; learns review protocols and provides ongoing support to ensure timely and accurate processing of all surgery-related cases.
Issues compliant denial determinations for full or partial payment of bills within the required timelines, ensuring all CARC and RARC codes align with the NYS WCB e-billing mandate and associated crosswalk guidance.
Responsible for the technical handling and review of disputed medical bills (HPs) including administrative and arbitration disputes; prepares detailed objections and ensures proper application of CARC/RARC codes in accordance with WCB and fee schedule rules.
Provides a high level of customer service and professionalism, demonstrates a dependable work ethic and collaborates with Bill Unit Manager and Nurse Case Manager to ensure compliance with the NYS Workers’ Comp Board regulations and timely resolution of billing disputes and appeals.
Reviews monthly Procedural Penalty Statement associated with the HP awards; issues timely objections or payments and maintains a detailed, audit ready log of penalty activity.
Responds to written or verbal inquiries from providers or internal teams regarding bill review determinations; ensures responses are technical and accurate and in accordance with the appropriate Fee Schedule.
Updates Medata Provider/Payee information (including TIN locks and notes) and assists with maintaining provider and claim records, identifying duplicates, and running reports as needed.
Reviews, analyzes, adjusts and releases queued bills to ensure timely payments in Medata/Toolbox/Image Right.
Assist the bill review team by reviewing and processing lower-complexity bills to support departmental turnaround times and maintain workflow continuity.
Issue payment of bills within 30 days of receipt as needed.
Provide back-up support for Bill Unit Manager with the monthly Hospital Surcharge Report.
Performs additional special projects or related assignments as directed by the Bill Unit Manager or departmental leadership.