Medical Review Analyst I

US-FL-SUNRISE
1 month ago
Requisition ID
2017-2348
Category
Medical Case Management
Business Unit
Broadspire

Excellence In Everything We Touch

Broadspire Claims

Position Summary

 

 

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.

 

 

Responsibilities

 

  • 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.

     

 

Requirements

 

  • Needs to be a LPN or RN.
  • Five years of Workers Compensation bill review with ability to independently coordinate processing inpatient fee-schedule, usual and customary and DRG states bills with knowledge of surgical/ASC review.
  • Five years of Workers Compensation bill review with ability to independently coordinate processing surgical bill review with knowledge of inpatient bill review.
  • Ability to act as consultant on most varied, complex cases of the department.
  • Maintains licenses per jurisdictional requirements and business need.
  • Willingness to obtain other state licenses as requested.
  • Must type 30 words per minute, have working knowledge of personal computers with the ability to use standard word processing software applications and strong written and verbal communication skills are required.

 

About Us

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:

  • Career advancement potential locally, nationally and internationally. Crawford & Company has more than 700 locations in 70 countries;
  • On-going training opportunities through every stage of your career
  • Strong benefits package including matching 401k; health, dental, and life insurance; employee stock purchase plans; tuition reimbursement and so much more.

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. 

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