RN - Medical Bill Audit Specialist - Sarasota

Position Description:


Responsible for review, analysis and reduction of national medical utilization and compensation. Under administrative direction, exercises discretion and independent judgement to provide a thorough professional review of complex medical billing, potentially including written and verbal interpretation of that review if a case goes to trial. May involve assisting with special projects and performing some triage and/or case management duties.
Reviews and audits medical bills and re-evaluations from multiple states to assess compensation and medical necessity as well as negotiates appropriate payment.


Makes decisions and resolves issues regarding medical bill disallowances and disputed charges with outside facilities and providers both verbally and in writing. Includes applicable workers' compensation statutory requirements and fee schedule(s) in decision-making process. Documents conversations and agreements in claims system and sends confirmation /verification letters.


Acts as a resource to Bill Review and communicates appropriate payment amounts.


Develops and maintains relationships and partnerships with medical providers and facilities. Handles provider and/or client correspondence requiring medical expertise and decision-making regarding bill payment.


Works with Corporate Provider Fraud Unit to identify possible medical services and/or billing fraud. Prepares for and attends workers' compensation trials as necessary


Maintains records, identifies and addresses trends in billings practices.


Processes pre-authorization reviews and authorizes payment for treatment in compliance with jurisdictual statutes and company standards.


Consistently and accurately documents interventions and rationale for decisions in the appropriate claim system screen.


May assist with special projects and assume other responsibilities as assigned, including case management and First Call triage.
 
Position Requirements:


Maintains clear and active RN license in state(s) employed.


Pursues continuing education to maintain RN active status, in technical areas related to Workers' Compensation injuries, illnesses and bill auditing.


Possesses or pursues additional professional designations such as CIRS, CCM, CRRN.


Maintains knowledge of Workers' Compensation statues and changes in multiple states through self-development program including research, reading and attending classes or seminars.


Maintains strong written and verbal communication skills. 
 




REF: CAAR162219

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