PRIMARY PURPOSE: To review hospital and professional medical bills from provider including complex hospital, surgical, high level evaluation and management codes, and/or technical bills.

 ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Processes bills in accordance with multi state schedules, rules, regulations, and guidelines.
• Applies PPO contract discounts to bills.
• Reviews operative reports to determine if surgery services were appropriately billed.
• Reviews complex medical, legal and consult services.
• Contacts client or facility to obtain additional or missing information.
• Handles provider appeals where appropriate to fee schedule and contractual disputes.
• Communicates internal issues to management.
• Assists bill review team lead with workflow management, coaching and mentoring of staff.
• Assists with process, procedure and system training for new staff.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travel as required.

QUALIFICATIONS

Education & Licensing

High School diploma or GED required.

Experience

Two (2) years workers' compensation and/or bill review experience or equivalent combination of education and experience required to include provider appeals experience. PPO re-pricing, surgery review, by report and RNE review preferred. Two (2) years of experience with complex medical, legal, and consult review preferred.

Skills & Knowledge

• Knowledge of re-pricing rules and guidelines
• Knowledge of medical terminology, anatomy and surgical terms
• Knowledge of multiple state jurisdictional regulations and rules
• Knowledge of Fee Schedules, Rules, and U&C Guidelines
• Knowledge of CPT/ICD9
• PC literate, including Microsoft Office products
• Leadership skills and ability to motivate others
• Strong verbal and written communication skills
• Strong interpersonal skills
• High level of accuracy and attention to detail
• Ability to multi-task and function in high volume area
• Ability to handle deadlines and proactively problem solve
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $.19.00. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.