Clinical Review Specialist - Medical Billing Review

Location
Suwanee, Georgia
Salary
Not Specified
Posted
Nov 19, 2020
Closes
Jan 18, 2021
Ref
78220110#GIJ--LibertyMutual.1
Job Type
Not Specified
Career Level
Not Specified

At Liberty Mutual, our purpose is to help people embrace today and confidently pursue tomorrow. Thats why we provide an environment focused on openness, inclusion, trust and respect. Here, youll discover our expansive range of roles, and a workplace where we aim to help turn your passion into a rewarding profession.

Liberty Mutual has proudly been recognized as a Great Place to Work by Great Place to Work US for the past several years. We were also selected as one of the 100 Best Places to Work in IT onIDGs Insider Pro and Computerworlds 2020 list. For many years running, we have been named by Forbes as one of Americas Best Employers for Women and one of Americas Best Employers for New Graduatesas well as one of Americas Best Employers for Diversity. To learn more about our commitment to diversity and inclusion please visit: https://jobs.libertymutualgroup.com/diversity-inclusion

We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: https://LMI.co/Benefits

Liberty Mutual is an equal opportunity employer. We will not tolerate discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, veterans status, pregnancy, genetic information or on any basis prohibited by federal, state or local law.

As a Clinical Review Specialist, you will monitor and/or review medical bills for cost containment and perform audits of hospital bills or other institutional bills. You will serve as liaison with the medical community, advise staff on ways to control costs, and negotiate rates for medical services and supplies. You will directly interact with the bill payment team on quality, production, and training issues and be responsible for compilation of a detailed summary and analysis of medical records and recommendations on the medical management of submitted cases.

Responsibilities:

  • Perform hospital bill review including desk and on-site hospital bill auditing; provides recommendations on appropriate payment of medical bills and posts files to explain adjustments.
  • Negotiate fees with providers, hospitals, and extended care facilities and maintains current database for new medical trends and unscheduled procedures along with specific jurisdictional fee schedules.
  • Review incoming medical bills and/or analyzes product and general liability.
  • Maintain current database including log of monthly activity on all reviewed cases from assignment to completion.
  • Analyze medical records related to the case files referred and makes recommendations as to the compensability of medical care provided.
  • Provide assistance on medical arbitration.
  • Prepare and submits dispute resolutions to appropriate state agencies.

*This position is a range posting, grades 12-13 dependent on candidates' experience and qualifications.*

  • Degree from an accredited nursing school required (prefer Bachelor of Science in Nursing or a B.S. in a related field).
  • Minimum 3-5 years of clinical nursing experience; prefer previous orthopedic, hospital, or rehab care experience.
  • Must have a minimum of 2 years of utilization review or relevant bill auditing experience for a total of 5-7 years of work experience.
  • Must have current unrestricted registered nurse (R.N.) license in the state where the position is based.
  • Must also have and maintain an AAPC (American Academy of Professional Coders) coding certification, such as CPC, CPC-H or RHIA.
  • Ability to analyze medical records and medical coding, make sound nursing judgments, and accurately document activities.
  • Strong verbal and written communication skills in order to effectively communicate with medical professionals, medical bill review staff, claims staff, state agencies, and others. Good negotiation skills to effectively negotiate fees with medical providers.
  • Demonstrates effective training and mentoring skills. Ability to handle multiple and conflicting priorities.
  • Advanced typing skills and proficiency using common software applications such as Internet Explorer and Microsoft Office (including Word, Excel, and Outlook).
  • Advanced knowledge of state, local and federal laws related to health care delivery and billing preferred.

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