NEXUS

Coder – Specialty Medical Bill Reviewer

NEXUS

full-time

Posted on:

Location Type: Remote

Location: Texas • United States

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About the role

  • Responsible for auditing medical bills to ensure that they are appropriate and adhere to the State Fee Schedules, customer guidelines, and PPO discounts
  • Analysis and review of 1 or more assigned states having fee schedules
  • Utilize Fee Schedules, Online Documents, Client instructions, and other training material to properly review medical bills
  • Review medical bills for compensability and relatedness to injury
  • Reprice medical bills to Workers’ Compensation Fee Schedule and PPO Network
  • Research usual and customary/fee schedule applications and system interface as appropriate
  • Reviews specialized Medical Bills, which include hospital, surgery, and high-level physician bills for workers' compensation and non-workers' compensation claims, and may include hospital bills, auto liability, and usual and customary reimbursement
  • Determines the appropriateness of a final reimbursement outcome by making the distinction between and knowing when to apply either Fee Schedule reduction, PPO reduction, Usual and Customary reduction, or Medicare reduction
  • Communicates and defends to providers and clients the basis for the methodology used to accomplish the reduction of charges
  • Analyzes and reviews high-level office visits, reports, and record reviews
  • Interprets hospital review guidelines for both inpatient and outpatient claims
  • Responsible for producing a final review for the recommendation of payment to the client
  • Maintain productivity, as well as speed and level of accuracy, as determined by company standards

Requirements

  • Current knowledge of utilization review processes and managed care
  • Knowledge of state-based fee schedules
  • Strong knowledge of Medical Terminology and CPT/ICD-9/ICD-10 coding
  • Ability to identify trends through analysis of practices to improve the overall utilization of resources and cost containment
  • Ability to communicate those trends found through analytical study using a variety of reporting mediums
  • Ability to work collaboratively and independently while meeting productivity standards
  • Ability to work in a high-production environment while meeting productivity and quality standards
  • Ability to represent Utilization Management in organizational committees, as assigned
  • Excellent relationship management skills
  • Demonstrated ability to problem-solve in complex situations
  • Ability to engage in abstract thought
  • Strong organizational and task prioritization skills
  • Strong analytical, numerical, and reasoning abilities
  • Well-developed interpersonal skills
  • Ability to establish credibility and be decisive – while also recognizing and supporting our organization’s preferences and priorities
  • Results-oriented with the ability to balance other business considerations
  • Knowledgeable of multi-state workers’ compensation systems
  • Computer literacy on Microsoft Office products and database programs
  • Ability to construct grammatically correct reports using standard medical terminology
  • Must have a track record of producing highly accurate work, demonstrating attention to detail
  • High School Diploma or equivalent
  • AAPC Coding Certification required (CPC required, CIC preferred)
  • ICD-9, ICD-10, PCS/HCPS/CPT, MS-DRG, and Geographical codes, and NCQA regulatory compliance guidelines
  • Must have a consistent coding rate at the 95th percentile or higher
  • RAC review and auditing
  • Proficiency as a Specialty Medical Bill Reviewer with two or more years of previous experience in medical bill review (workers’ compensation is a plus)
Benefits
  • Equal Employment Opportunities (EEO)
  • Inclusive environment for all team members and applicants
  • Encourages veterans to apply
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
medical billingfee schedule analysisCPT codingICD-9 codingICD-10 codingutilization reviewdata analysisreportingmedical terminologyRAC review
Soft Skills
relationship managementproblem-solvingorganizational skillsanalytical skillsinterpersonal skillscommunication skillsattention to detailcollaborationdecisivenessresults-oriented
Certifications
AAPC Coding CertificationCPCCICICD-9 certificationICD-10 certificationPCS certificationHCPCS certificationNCQA compliance certificationMS-DRG certificationstate-specific certifications