Medical Review Specialist

3 weeks ago

Rockford, Illinois, United States Examworks Group, Inc. Full time

Overview:


Looking for an opportunity to utilize your exceptional coding skills in the fast-paced and dynamic healthcare services industry? Look no further because ExamWorks is looking for you to fill their Medical Review Specialist role.

To be considered, you must possess one of the following current certifications: CPC, CCS, CMC, RHIT. Based on business needs, certain units may require a specific certification in order to perform the role.

The Medical Review Specialist is responsible for creating and writing reports based on medical records and appropriate guideline criteria.

This position utilizes the system database to determine usual and customary and/or state fee schedule allowances and this position is responsible for analyzing provider billing for proper coding and billing guidelines across all provider types and ensures reviews are completed with highest quality and integrity and that all work is in full compliance with client contractual agreements, regulatory agency standards and/or federal and state mandates.

The position is 100% remote with a schedule of Monday-Friday 7:30am-4:00pm CT.

Are you motivated, energetic, and excited to become part of the ExamWorks team? If so, you might be our next new team member

Responsibilities:
Performs quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.

Billing / coding appeal level reviews.

Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.

Ensures that all client instructions and specifications have been followed and that all questions have been addressed.


Ensures each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications.


Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.


Verifies that the peer reviewer has attested to only the fact(s) and that no evidence of reviewer conflict of interest exists.

Ensures the provider credentials and signature are adhered to the final report.

Identifies any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed.

Assists in resolution of customer complaints and quality assurance issues as needed.

Reviews each claim and addresses all necessary modifications manually. Including reviewing and applying any applicable coding and/or billing guidelines per industry standards and/or specific client requests.

Contacts client to resolve questions, inconsistencies, or missing data needed for review.

Performs quality assurance on every case prior to completion.

Provide notification to the Supervisor of any provider appeals and follow directions as given to resolve the claim.

Communicates any issues, errors, or questions concerning the medical review bill system with management and/or with the IT helpdesk.


Ensures all practices are carried out in accordance with HIPAA compliance practices, state and federal safety standards and legal regulations.

Promotes effective and efficient utilization of clinical resources and supplies.

Performing quality assurance on various coding related reviews.

Perform other duties as assigned.

Qualifications:
High school diploma or equivalent required. Minimum one year medical billing experience; or equivalent combination of education and experience required.

Must possess one of the following current certifications: CPC, CCS, CMC, RHIT. Based on business needs, certain units may require a specific certification in order to perform the role.

Minimum one year medical billing experience; or equivalent combination of education and experience required.

Must have a full understanding of aspects of medical billing.


Must have full understanding of the various types of medical billings and ability to identify which system database should be used.

Must be able to cross reference different types of billings to ensure consistency in the review process.


Must possess knowledge of standard fee schedule review, UC&R review, drug and supply charges, rarity, utilization review, CPT guidelines, ICD 10, bundling/unbundling, duplicate billing and CMS reimbursement guidelines.

Must possess complete knowledge of general computer, fax, copier, scanner, and telephone.

Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.

Must have a full understanding of HIPAA regulations and compliance.

Must be a qualified typist with a minimum of 35 W.P.M.

Ability to follow instructions and respond to managements' directions accurately.

Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.

Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.

Must be able to work independently, prioritize work activities and use time efficiently.

Must be able to maintain confidentiality.

Must be able to demonstrate and promote a positive team -oriented environment.

Must be able to stay focused and concentrate under normal or heavy distractions.

Must be able to work well under pressure and or stressful conditions.

Must possess the ability to manage change, delays, or unexpected events appropriately.

Demonstrates reliability and abides by the company attendance policy.

Must maintain a professional and clean appearance at all times consistent with company standards.


ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services.

Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages.

ExamWorks offers a fast-paced team atmosphere with competitive benefits, paid time off, and 401k.


ExamWorks, LLC is an Equal Opportunity Employer and affords equal opportunity to all qualified applicants for all positions without regard to protected veteran status, qualified individuals with disabilities and all individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age or any other status protected under local, state or federal laws.

Equal Opportunity Employer - Minorities/Females/Disabled/Veterans

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