Audits inpatient and/or surgical bills in accordance with State, Federal and company guidelines. Establishes and maintains effective working relationships with internal and external customers. Possesses working knowledge of information systems and resources available to meet needs of clients accounts, Branch Claim Offices (BCO’s) and claims group. Performs moderate to complex inpatient and surgical bill review under the direction of an immediate supervisor or Senior Medical Review Analyst. Knowledge is broader across lines of business, bill types, assigned states, fee guidelines, and jurisdictional rules.
Process inpatient and/or surgical bills per state guidelines. Promotes excellence of the bill review process by participation in the QA process and through active participation in the
Department’s process improvement efforts.
Plans and organizes individual caseload to meet department objectives. Utilizes appropriate resources to perform the bill review process, this includes but is not limited to Medical
Bill Review Adjudication System, Claim System, State or Legislative National Repricing Tools, Fee Databases, State Fee Schedules and UB Editor.
Clarify billing discrepancies and obtain service verification in order to appropriately analyze and recommend reimbursement. Documents pertinent information in the system bill notes to support reimbursement determination.
Perform reconsideration of bills, per provider’s request to ensure the original bill processing determination is appropriate.
Assist Customer Assistance and PPO departments with bill issues, questions on fee-schedules and/or ground rules for a particular state. Precept new staff within the department as requested.
Communicates effectively with providers, patients, CMO/Peer Physicians, adjusters and others involved in the case management process as needed. Communicate to manager/supervisor any pertinent information; discrepancies or issues within are of responsibility to ensure an accurate and productive working environment. Provide input to company attorneys to assist in possible litigated claims.
Researches, reviews and prepares medical information to present and collaborate objectively with CMO/Peer Physicians in order to facilitate determination of reimbursement.
Inform appropriate personnel system issues related to calculation of reimbursement to determine training needs and ensure the production of a quality product.
Broadspire (www.choosebroadspire.com), a leading international third party administrator, provides risk management solutions designed to help clients improve their financial results. Broadspire offers casualty claim and medical management services to assist large organizations in achieving their unique goals, increasing employee productivity and reducing the cost of risk through professional expertise, technology and data analytics. As a Crawford Company, Broadspire is based Atlanta, Ga., with 85 locations throughout the United States. Services are offered by Crawford & Company under the Broadspire brand in Europe (www.Broadspire.eu), including the United Kingdom (www.BroadspireTPA.co.uk).
In addition to a competitive salary, Crawford offers you:
Crawford & Company participates in E-Verify and is an Equal Opportunity Employer. M/F/D/V
Crawford & Company is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at Crawford via-email, the Internet or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be deemed the sole property of Crawford. No fee will be paid in the event the candidate is hired by Crawford as a result of the referral or through other means.