Nurse Medical Bill Auditor - Medical Bill Review
Employment Type: Full-Time
This job can be filled in any of our Zenith Branches with preference in our Orange, CA or any other CA Branch Office
Responsible for clinical review and analysis and appropriate adjustment of billing as needed based on Workers Compensation fee schedules and guidelines or other jurisdictional pricing applications. Uses independent judgment to negotiate and communicate with medical providers to obtain the best outcome. Assists management in identifying areas of opportunity based on current medical billing environments. Provides written and verbal interpretation of reviews if a contested case goes to trial. Partners with effective interaction with claims and claims legal. May involve assisting with special projects.
The essential functions of this position include, but are not limited to, the following:
* Analyzes and audits medical bills from multiple states in order to verify, adjust, or recommend payment in accordance with state fee schedules, coding guidelines, healthcare regulations and medical compliance. Monitors billing for trends.
* Communicates with providers regarding disputed claims and payments.
* Ensures an ongoing working relationship with providers.
* Advises Legal department on fee schedule guidelines, billing rules and medical compliance/standards. Consults Legal on bill reimbursement and state appeals.
* Evaluates and negotiates high dollar bills that have the potential for significant savings and/or reconcile outstanding provider balances to mutual satisfaction.
* Represents the company at the state level when involved with workshops, state appeals, hearing disputes, and legislative hearings.
* Provides resources to Bill Review analysts and management for special projects, training, and reports.
* Advocate a collaborative working relationship with claims and advise on particular bills or payment strategies.
* Performs other job related duties as assigned.
* Maintains clear and active license in state(s) employed
Pursues continuing education to maintain licensure active status, in technical areas related to Workers´ Compensation injuries, illnesses and bill auditing.
* Possesses or pursues additional professional designations such as coding certifications from AHIMA/AAPC/CMAS.
* Maintains strong written and verbal communication and negotiation skills.
Education, Skills and Experience Requirements
* 3-5 years (minimum) of clinical experience in Orthopedics, ER, Occupational Health and/or Neurology/Neurosurgery.
* Experience with/understanding of utilization/bill review, claims, managed care processing; Workers´ Compensation
* Bill Audit experience, including knowledge of workers´ compensation laws/fee schedules in most states, preferred
* Active and clear health professional license. RN preferred but will consider other para-professional with extensive, relevant coding and bill auditing experience.
* Excellent negotiation, problem solving and analytical skills and strategies.
* Excellent interpersonal and communication skills oral and written. Must be able to communicate effectively with all levels of staff.
* Experience with Windows (3.1 or higher), Microsoft Office, and Excel.
* Qualifications may warrant placement in a different job level*