Bill Review Specialist

ABOUT US:

Ethos Risk Services is a leading provider of workers compensation medical management investigations and claims solutions dedicated to helping clients make better decisions through industry expertise innovation and exceptional service. As we continue to grow were expanding our cost containment capabilities through Definiti a national leader in medical bill review pharmacy benefit management PPO network solutions and reimbursement services. Together were building a comprehensive suite of solutions that helps clients reduce costs improve efficiency and achieve better claim outcomes.

JOB SUMMARY:

Our dynamic Bill Review team is seeking a full-time Bill Review Specialist (REMOTE) to review audit and process workers compensation medical bills while ensuring compliance with state fee schedules regulatory requirements and client-specific guidelines. The ideal candidate is analytical organized and committed to delivering accurate high-quality work in a fast-paced environment.

KEY RESPONSIBILITIES:

• Analyze Medical Bills Review and adjudicate hospital ambulatory surgery center (ASC) durable medical equipment (DME) pharmacy transportation home health and other specialty medical bills for reimbursement accuracy and compliance.
• Research Provider Appeals Investigate provider appeals reconsiderations and billing disputes by interpreting applicable fee schedules reimbursement methodologies regulations and client guidelines.
• Prepare Reimbursement Determinations Draft clear professional written correspondence explaining payment decisions and reimbursement methodologies to providers.
• Communicate with Providers Respond to provider inquiries via phone and written correspondence regarding reimbursement decisions payment methodologies and billing questions.
• Support Cross-Functional Teams Partner with the Account Management team and other internal stakeholders to resolve billing issues answer client questions and support operational objectives.

QUALIFICATIONS:

Education: High school diploma or equivalent (required). Associates degree or higher is preferred.

Experience:

• Minimum of 3 to 5 years of workers compensation bill review experience reviewing and adjudicating medical bills using state fee schedules PPO contracts reimbursement methodologies client guidelines and applicable workers compensation regulations. (required).
• Knowledge of CPT ICD-10 HCPCS (required).
• Experience using Conduent Strataware software (preferred).
• Experience in billing accuracy reimbursement eligibility code relationships bundled services modifier usage and reimbursement calculations while applying regulatory and client-specific guidelines (required).
• Experience applying multi-state workers compensation fee schedules reimbursement methodologies payment policies and jurisdiction-specific regulations (preferred).
• Experience researching complex reimbursement issues fee schedules and regulatory guidance to support accurate and defensible payment determinations (preferred).
• Experience managing provider appeals reconsiderations and billing disputes including communicating reimbursement methodologies and payment decisions (preferred).
• Experience reviewing complex medical bills including hospital ASC DME transportation home health dental and other specialty bill types involving advanced reimbursement analysis (preferred).

WORKING CONDITIONS:

This position offers flexible work arrangements including remote hybrid or full on-site options. If your preference is hybrid or remote our office is located at 26445 Rancho Parkway Street Lake Forest CA 92630.

Flexible start times are available between 6:00 a.m. and 9:00 a.m. with eligibility for a 9/80 alternate work schedule (every other Monday or Friday off) following successful completion of training satisfactory performance business needs and management approval.

Ethos Risk Services and Definiti Comp Solutions is an equal opportunity employer that does not discriminate on the basis of religious creed sex national origin race veteran status disability age marital status color or sexual orientation or any other characteristic.

Required Experience:

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