Lead Medical Billing Review Specialist

2 weeks ago


Milwaukee, Wisconsin, United States Rising Medical Solutions Full time
Position Overview

RISING Medical Solutions, a leading provider of financial solutions in the healthcare sector, specializes in medical cost management and care coordination services. Our extensive network includes offices, healthcare providers, and case managers across the nation, delivering comprehensive medical claims solutions to our esteemed clients, which include insurance companies, major corporations, third-party administrators, and governmental entities.

Our Commitment:

  • Continuous enhancement of technology
  • Fostering an entrepreneurial spirit
  • Upholding seven core values that prioritize teamwork, ethical conduct, customer satisfaction, ongoing improvement, a positive mindset, focusing on key priorities, and maintaining a sense of humor
  • Promptly addressing client requirements
  • Aiming to be the best in our field, rather than the largest

Role Summary:

The Lead Medical Billing Review Specialist is responsible for optimizing client savings by meticulously evaluating and processing medical invoices in accordance with applicable state regulations, fee schedules, industry benchmarks, relevant network agreements, specific client directives, and organizational policies.

Key Responsibilities:

  • Consistently embody all company Core Values
  • Assess small to medium-sized medical bills for payment recommendations, taking into account state workers' compensation regulations, fee schedules, customary rates, current PPO agreements, coding and bundling standards, client guidelines, claim history, and company protocols
  • Meet production targets to ensure timely processing as per client agreements
  • Achieve accuracy in payment processing
  • Create clear and concise Explanation of Review (EOR) documents and correspondence
  • Engage in continuous training to remain compliant with procedural updates and to enhance professional skills
  • Participate in team discussions to share knowledge and insights related to job functions, the organization, and the industry
  • Adhere to HIPAA and ARRA regulations

Reporting Structure:

This position reports to the Operations Manager.

Qualifications:

  • High School Diploma required; some college education preferred
  • State Certification or certification in a related discipline (e.g., CPC) is advantageous
  • A minimum of 4 years of experience in medical billing or a related field
  • Experience in the workers' compensation sector is a plus
  • Proficiency in Microsoft Windows and Office Suite (Word, Excel, Outlook, etc.)
  • Strong data entry skills with a minimum speed of 10,000 keystrokes per hour and an accuracy rate of at least 93%
  • Ability to read, analyze, and interpret technical documents, state regulations, coding/bundling guidelines, and fee schedules
  • Effective communication skills, both written and verbal, to interact with colleagues, clients, and providers
  • A commitment to personal and organizational growth
  • Mathematical skills for calculating PPO discounts, savings adjustments, percentage fees, and negotiations
  • Practical problem-solving abilities
  • Capability to organize tasks and set priorities
  • Ability to foster a collaborative work environment
  • Exceptional attention to detail
  • Patience for performing routine tasks consistently
  • Strong time management skills

Physical and Mental Requirements:

  • Ability to remain seated for extended periods
  • Proficient in data entry tasks
  • Visual acuity for reviewing documents
  • Effective verbal communication
  • Active listening skills
  • Repetitive motion involving hands and fingers
  • Work typically conducted in a standard office environment

Employee Benefits:

  • Comprehensive health insurance options
  • Dental and vision coverage
  • Paid time off or flexible time off
  • 401(k) retirement plan
  • Basic life and long-term disability insurance provided by the company
  • Optional life and short-term disability insurance
  • Flexible spending accounts
  • Employee assistance program
  • Wellness initiatives
  • Professional development reimbursement opportunities
  • Participation in our employee recognition program


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