Review and process workers' compensation medical bills to ensure accurate reimbursement in accordance with state regulations, fee schedules, utilization review requirements, and company policies. The role involves researching and resolving billing issues, generating explanation of reimbursement documents, performing manual pricing when needed, and communicating with providers, claim professionals, customers, and internal stakeholders regarding claim status and reimbursement determinations.
The specialist must consistently meet productivity, quality, and service standards while completing work accurately and within required timeframes.
Responsibilities include:
- Review workers' compensation medical bills and apply appropriate cost containment measures.
- Verify billing information, identify discrepancies, and resolve missing or incomplete documentation.
- Apply reimbursement guidelines, fee schedules, and billing regulations.
- Escalate complex cases for technical review when needed.
- Maintain current knowledge of workers' compensation laws, regulations, and bill review processes.
- Contact providers and other parties to obtain missing information.
- Enter and validate claim and billing data in the repricing system.
- Generate and review Explanation of Reimbursement (EOR) documents.
- Perform manual bill calculations and adjustments when automated pricing is unavailable.
- Respond to inquiries from providers, customers, claimants, and internal partners.
- Recommend process improvements to improve efficiency, accuracy, and service.
- Maintain confidentiality and comply with privacy and regulatory requirements.
Required qualifications
- High school diploma or equivalent.
- Minimum of 2 years of experience in claims processing, medical billing, medical bill review, workers' compensation, healthcare reimbursement, or a related field.
- Strong attention to detail and ability to process high volumes accurately.
- Strong data entry and computer skills.
- Effective verbal and written communication skills.
- Strong organizational and time-management abilities.
- Ability to prioritize multiple tasks and meet productivity and quality standards.
- Ability to interpret and apply policies, procedures, and reimbursement guidelines.
Preferred qualifications
- Experience with workers' compensation medical bill review or medical cost containment.
- Knowledge of utilization review principles within workers' compensation programs.
- Familiarity with the Pennsylvania Workers' Compensation Bureau Utilization Review process.
- Understanding of medical terminology, CPT, HCPCS, ICD, and other coding systems.
- Knowledge of medical fee schedules, reimbursement methodologies, and provider billing practices.
Location
N/A
Employment Type
Not specified
Experience Level
Associate
Remote work allowed
Yes
Posted
1 week ago