Bill Review (BR) Nurse Specialist

EK Health
Job LocationUS
Job TagEarly Career

Description:

Location: Remote

Under the direction of the Provider Network Manager, the Bill Review Nurse Specialist is responsible for utilizing clinical acumen and medical review/audit expertise related to reviewing workers’ compensation medical bills, including but not limited to:

The Bill Review Nurse Specialist will also work with providers targeted to join EK Health’s Provider Network, enter into a direct contract relationship or individual bill retrospective negotiations with EK Health.

Responsibilities:

  • Reviewing medical records, itemized statements and other documentation to perform retrospective review/audit of high dollar, complex procedure and/or other “at risk” bills as determined by Provider Network Manager and AVP of Bill Review Services.
  • The Bill Review Nurse Specialist performs a complete review of medical records associated with the bill and a line-by-line thorough audit of the itemized bill and other documentation scrutinizing for the following:
  • Potential billing errors
  • Charges not supported by documentation
  • Charges not related to the work comp injury (if the accepted injury is available to us)
  • Charges that should not be unbundled
  • Diagnosis Related Group Validation
  • Implant verification/proof of service
  • Correct use of CPT, Diagnosis, Procedure, HCPCS codes as well as modifiers
  • Unlisted or BR code verification and/or re-pricing
  • Other items as determined by the Provider Network Manager and/or AVP of Bill Review Services
  • Accurately and appropriately analyze complex medical bills and make payment recommendations based on claim history, medical notes, usual and customary rates (UCR), statutory regulations including state laws and fee schedules, available MPN/PPO contracts, coding guidelines, client instructions, and company policies and procedures
  • Research and apply applicable guidelines, and document clear and concise notes related to the recommendations along with related rationales
  • Perform coding analysis. e.g. Medically Unlikely Edits (MUEs), Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT), Diagnosis Codes, modifiers, DRG etc.
  • Engage with medical providers to retrospectively negotiate individual medical bills on behalf of our clients while creating long last relationships
  • Recruit providers to join EK Health’s Provider/Specialty Networks.
  • Negotiate and secure strategic agreements with providers that will be beneficial to our clients and the provider
  • Make/oversee targeted calls to providers to establish and maintain relationships with entities that join EK Health’s Networks
  • Obtain and maintain required documentation from providers wishing to join EK Health’s Provider Networks
  • Communicate with medical providers to obtain needed information and resolve bill-specific issues
  • Respond to issues and drive problem resolution in a quick turn- around time
  • Participate in ongoing training to enhance job skills and knowledge
  • Maintain emphasis on privacy and confidentiality in all review interactions and completions
  • Complete assigned cases accurately, meeting all regulatory and compliance timelines
  • Continuous working knowledge of Ahshay and the BR system
  • Demonstrates advanced knowledge of ICD-9/10 coding.
  • Demonstrates advanced knowledge of HCFA billing and CPT and HCPCS coding.
  • Demonstrates advanced knowledge of UB billing, Primary Procedure codes, revenue codes and jurisdictional direction regarding use.
  • Demonstrates advanced knowledge of CCI edits.
  • Expedites productivity to support and ensure timely Nurse Audit Review of complex HCFA & UB bill
  • Acknowledges and adhere to EK Health policies and procedures
  • Maintain acceptable attendance and tardiness; must be punctual and dependable
  • Participate in the team meetings, BR meetings and weekly one on one meetings with Provider Network Manager
  • Professional demeanor with excellent written and oral communication skills
  • Strong organizational and time management skills
  • Other duties as assigned by Provider Network Manager

Qualifications:

  • LPN or RN with an active and unencumbered license
  • Minimum five years clinical nursing experience
  • Minimum 3 years’ experience in performing complex Work Comp Medical Bill Nurse Audit reviews with provider relations exposure preferred
  • Knowledge of ICD-9/10, HCPCS ,CPT, Modifier & DRG coding procedures
  • Must demonstrate the ability to understand state laws and utilization guidelines as they apply to bill review activity.
  • Must be computer literate with a high comfort level with computer programs including but not limited to MS Word, MS Excel, Email and Internet
  • Advanced knowledge of medical terminology
  • Ability to read, analyze, and interpret technical procedures, medical reports, state laws and fee schedules
  • Possess nationally recognized coding credentials preferred but not mandatory
  • Excellent Written and Oral Communication Skills
  • Excellent Interpersonal & Organization Skills
  • Ability to work independently with minimal supervision
  • Ability to meet deadlines in a high pressure, time sensitive environment
  • Ten key proficient
  • Excellent typing skills
  • Must be accurate and efficient
  • Ability to lift up to 20 lbs
  • Physical Requirements:
  • Candidate must be able to sit the majority of an 8-hour day except for lunch and break times.
  • Candidate must be able to keyboard the majority of an 8-hour day except for lunch and break times. Candidate must have manual dexterity.
  • Candidate must be able to speak on the telephone intermittently throughout the day.
  • Candidate must be able to read and write English fluently.
  • Candidate must be able to provide and confirm safe home office environment.
  • Home office must be HIPAA compliant.
  • *Requires DSL, fiber or cable internet connection from home 10 Mbps preferred or better*
  • As an employee of EK Health Services, I hereby acknowledge that I have read and fully understand the responsibilities the Bill Review (BR) Nurse Specialist as outlined herein and that I am able to perform the job duties outlined and described above for the position, with or without reasonable accommodation.

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