Medical Bill Review Operations Analyst (Remote)

Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured workers successful and speedy return to work is good for people and good for Berkleys insurance operating units. BMMS was first started in 2014 by reimagining the relationship between medical need and technology as a way to deliver the best outcome for injured workers and Berkleys operating units. Our goal was clear: combine solid clinical practices proven return-to-work strategies and robust software into one system for seamless management of workers compensation cases.

To get it right we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give W.R. Berkley Companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology software platforms data analytics and professional services ensures we provide Berkleys operating units with reliable results and reduced time and expenses associated with case management.

The position serves as a subject-matter expert for Medical Bill Review (MBR) operations providing advanced production support driving process improvements and coordinating cross-functional issue resolution and project execution. As an Operations Analyst you will support the processing of workers compensation medical and pharmacy bills from bill intake through bill payment and is a primary resource for issue resolution related to these processes. You will work directly with Berkley Operating Units to investigate bill processing issues and are responsible for problem-solving identifying and triaging issues to technical teams directly interfacing with multiple vendors to facilitate issue resolution issue documentation tracking and reporting. You may also work directly with medical providers and networks regarding billing issues. Well also look to you to independently and as part of a team identify issue commonalities and root causes to assist in solution design monitoring and controlling.

The position serves as a subject-matter expert for Medical Bill Review (MBR) operations providing advanced production support driving process improvements and coordinating cross-functional issue resolution and project execution. Core responsibilities include:

MBR Production Support & Issue Resolution

• Serve as the primary escalation point for complex MBR issues that cannot be resolved by Operations Technician/Level 1 support vendors or related internal teams (Clinical Validation Negotiations OU adjusters mailroom).
• Diagnose operational and adjudication issues by applying deep MBR process knowledge and collaborating with vendors and internal partners to resolve root causes.
• Provide backup Level 1 support including bill-level troubleshooting Jira ticket creation/maintenance report distribution and vendor communications.
• Maintain timely clear communication with Operating Units providers and stakeholders regarding issue status outcomes and required actions.

Operational Analysis Monitoring & Continuous Improvement

• Monitor business dashboards and vendor reports daily to identify and escalate adverse bill TAT trends identify likely root cause owners and track resolution progress.
• Recommend workflow enhancements rule updates and process changes to improve MBR accuracy efficiency and throughput.
• Document trends issues and resolutions to support auditability and continuous operational improvement.

Cross-Functional Collaboration

• Work closely with BMMS IT BAMTECH BTS Finance Data Reporting and MBR vendors to coordinate root cause investigations technical fixes and operational adjustments.
• Support Operating Unit staff by analyzing medical bill issues guiding next steps and ensuring a consistent professional experience.
• Build and maintain strong relationships with internal teams external vendors clients and medical providers.

Project Leadership

• Serve as the lead business resource for regulatory audit responses coordinating data gathering vendor input and documentation review prior to submission.
• Lead reconsideration projects including impact analysis bill resubmission coordination and monitoring outcomes.
• Partner with Business Analysts on MBR-related initiatives such as API implementations vendor transitions mailroom integrations and payment process enhancements.

Professional Standards & Administration

• Manage assignments in alignment with standard operating procedures meeting requirements and departmental expectations.
• Maintain issue tracking and ensure timely escalation of complex matters.
• Demonstrate professionalism tact and discretion in all interactions contributing positively to department morale and organizational reputation.

• MBR business process SME including experience with MBR E2E process from a business/operations perspective; firm understanding of integrated services and workflows including FS/UCR Nurse and code review PPO negotiations adjustor bill adjudication; workers compensation regulatory environment experience/understanding;
• Demonstrated application of successful critical thinking and complex problem solving skills;
• Experience in a role requiring deep understanding of and experience working with MBR and integrated services technology not at a developer level but from a business analyst perspective;
• Experience gathering business requirements and clearly documenting complex scenarios and use cases to communicate MBR issues accurately for resolution;
• Communication experience with varied audiences including leadership and peers in business/operational & technology roles;
• Client-facing acumen
• Team-player
• Experience with Atlassian/JIRA/SQL
• 5 years in a multi-faceted workers compensation MBR role demonstrating increasing responsibility with required skills outlined above within that time
  • or 3 years in an MBR role 2 years in position with similar responsibilities;