General Description

The Professional Review Specialist is a Certified Professional Coder or a specialized Bill Review Analyst with equivalent knowledge that provides analysis of medical services to determine appropriateness of charges on multiple types of medical bills and review of medical reports to determine appropriateness of medical care. Technical expertise is utilized to address the provision of medical care and to identify inappropriate billing practices and errors inclusive of, but not limited to; duplicate billing, unbundling of charges, services not rendered, mathematical and data entry errors, undocumented services, reusable instrumentation, unused services and supplies, unrelated and/or separated charges, quantity and time increment discrepancies, inconsistencies with diagnosis, treatment frequency and duration of care, DRG validation, service/treatment vs. scope of discipline, use of appropriate billing protocols, etc.

Essential Job Duties

• Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and/or direct reporting manager.
• Have knowledge of the applicable Fee Schedule and/or applicable U&C Guidelines.
• Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans.
• Document work completely, and document final conclusions in designated computer program.
• Adhere to regular and consistent work attendance.
• Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) and other requirements as outlined in the Employee Handbook.
• Be responsive to additional Professional Review job duties as assigned by management or determined by legislative changes and/or market changes.

Communication Requirements

The Professional Review Specialist must be able to communicate concisely and effectively in writing, and verbally, and must have the ability to interface with the claims adjusters, attorneys, physicians and their representatives, advisors/clients, and co-workers.

Required Education/Training

The position requires Certified Professional Coder (CPC) Accreditation by the American Academy of Professional Coders (AAPC) or equivalent accreditation by another nationally-recognized coding organization, and/or 2+ years of coding and data entry experience. Must be computer literate.

Preferred Education/Training

The Professional Review Specialist should have a thorough knowledge of both C.P.T. and I.C.D. diagnosis codes. Previous experience in the following areas is beneficial:

1. Medical bill auditing;
2. Knowledge of workers' compensation claims;
3. Prospective, concurrent and retrospective utilization review.

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Application Instructions

We are an Equal Opportunity Employer. All persons shall have the opportunity to be considered for employment without regard to their race, color, age, sex, gender, religion, national origin, ancestry, citizenship status, physical or mental disability, military service, veteran status or any other characteristic protected by applicable federal, state or local law.

We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this application or to participate in an interview, please let us know.

Please be aware that CorVel generally does not review all applications submitted in response to job openings posted on the Internet because of the large volume of responses.

Note to Employment Agencies: Please do not forward agency resumes. CorVel Corporation is not responsible for any fees related to unsolicited resumes.