Workers Compensation Medical Provider Appeals Analyst
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Job Description SummaryUnder general supervision this position is responsible for examining and evaluating previously paid moderate to complex medical bills, based on additional information submitted by medical providers, to determine and generate correct payment. Responding to escalated calls from medical providers regarding payment decisions for medical services. Responsible for keeping abreast of rules, regulations and contracts that are continuously changing.
Primary Job Duties & Responsibilities
- Perform a detailed review of previously submitted medical, hospital, durable medical equipment, pharmacy, home health et al bills along with accompanying reports/information for accuracy and to determine appropriateness.
- Using multiple screens on the Medical Bill Re-pricing System, read and interpret scanned medical reports to determine that services on bill were actually performed and coded to reflect the services that were actually provided.
- Compare bill and rates with appropriate fee schedules, clinical edits, Medicare, National Correct Coding Initiative (NCCI), internal Travelers protocols and PPO contracts to determine whether additional payment is due or if recovery of overpayment is necessary.
- Compile all medical bills to determine if there is overlap or duplication of any services.
- Apply payment policies to medical supplies and drugs/ medicine.
- Make accurate payments to medical providers based on the results and analysis of each medical bill.
- If original decision will be upheld, develop a formal response with supporting documentation. Commence recovery measures, when overpayment has occurred.
- Serve as the liaison between the provider and company including department leadership, Travelers Claim Product team and third party vendors.
- Regularly and independently identify and bring to managements attention any unusual/new medical procedures or billing anomalies identified during the review.
- In addition to day-to-day responsibilities, participates on high volume special projects in support of the New Product team.
- Deliver superior customer service to Travelers Claim professionals and those medical providers with escalated issues. Answer questions and analyze and resolve problems.
- High School Diploma or GED.
Education, Work Experience, & Knowledge
- College degree preferred and /or equivalent work experience.
- Previous Appeals experience reviewing workers compensation medical bills highly desirable.
Licensing or Certificates
- Certified Coder preferred or commensurate experience with the following resource materials:
- Current Procedural Terminology (CPT)
- International Classification of Diseases-9 (ICD-9) Revision
- Healthcare Common Procedural Coding System - 9th Revision (HCPCS) codes
- Itemized hospital bills, hospital records.
- Certified California Medical Bill Reviewer a plus.
Job Specific Technical Skills & Competencies
- Solid customer service telephone skills.
- Strong interpersonal communication skills.
- Strong verbal and written communication skills, including effective sentence construction, grammar, spelling, and punctuation. Basic computer skills: ability to toggle between multiple screens to find data that is needed to process medical bills.
- Proficiency in Microsoft Office products (e.g. Excel, PowerPoint, Word, Outlook).
- Good working knowledge of human anatomy and medical terminology preferred
- Working knowledge of Workers Compensation processes and procedures including fee schedule and payment rules preferred.
- Solid math skills: must be able to quickly and accurately add, subtract, multiply and divide with the assistance of a calculator.
- Proven ability and interest in staying abreast of new and emerging medical trends and literature.
- Strong attention to detail and ability to independently read and comprehend completely the details of a medical bill/report and notes and assess them against all appropriate rules and protocols.
- Strong comprehension and analytical skills
- Ability to produce high quality results in a high production environment
- Superior Organizational Skills and Attention to Detail
- Commitment to Task
- Continuous Learning
- Decision Making and Problem Solving skills.
- Sense of urgency
Travelers is an equal opportunity employer. We value the unique abilities and talents each individual brings to our organization and recognize that we benefit in numerous ways from our differences.
If you have questions regarding the physical requirements of this role, please send us an email so we may assist you.
Travelers reserves the right to fill this position at a level above or below the level included in this posting.