Workers' Compensation Medical Bill Review Appeals and Dispute Specialist

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm's business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs.

We're proud to be recognized-again For the fourth year in a row, we've been certified by Great Place to Work®, and for the third consecutive year, we've earned a spot on Fortune's Best Workplaces in Health Care™ list. These honors reflect our unwavering commitment to fostering a positive, inclusive, and employee-centric culture where people thrive.

Watch this short video for a brief introduction to Paradigm.

Paradigm is seeking a full-time, remote Provider Appeals and Legal Liaison. The Provider Appeals and Legal Liaison is responsible for leading the interface between the Medical Bill Review/Claims team and Paradigm's Legal department. This position manages complex medical provider appeals and reconsiderations, supports legal responses to medical billing disputes, and ensures compliance with Workers' Compensation regulations and best practices. The ideal candidate brings deep subject matter expertise, advanced analytical capabilities, and exceptional communication skills to drive resolution and influence cross-functional collaboration.

The schedule for this remote work position is Monday - Friday, 8 AM to 5 PM.

Responsibilities include (but are not limited to):

• Workers' Compensation Medical Bill Review and Provider Appeals
  Review and process provider appeals and complex billing reconsiderations for medical bills associated with complex Workers' Compensation claims
• Legal and State Dispute Support
  Act as the billing SME when disputes escalate to state WC boards. Display strong analytical & communications through compilation of end-to-end provider billing history, payment rationale, and regulatory citations to support Legal in drafting responses and negotiations.
• Jurisdictional Expertise
  Apply deep knowledge of Workers' Compensation regulations, statutes, and fee schedules across multiple states. Serve as SME for state-specific billing requirements and dispute processes.
• Medical Billing Standards and Compliance
  Maintain expertise in Workers' compensation fee schedules, medical billing and coding standards (CPT, ICD-10, HCPCS), and payer-side bill review methodologies, while ensuring compliance with all regulatory requirements.
• Trend Analysis and Process Improvement
  Identify patterns in provider disputes, recommend proactive solutions, and share best practices through training and collaboration.
• Cross-Functional Engagement and Documentation
  Represent Medical Bill Review in meetings with Legal, Compliance and Provider Relations. Maintain accurate, audit-ready records for appeals and disputes.

Qualifications:

• Bachelor's degree or equivalent experience required; advanced coursework in healthcare administration, legal studies, or medical billing preferred.
• Minimum 7 years of national Workers' Compensation bill review experience, with at least 3 years in a role involving appeals, reconsiderations, or legal coordination.
• Excellent written and oral communication skills and phone presence. Ability to effectively present information to providers as well as to employees of the organization
• Advanced understanding of medical billing, coding (ICD-10, CPT, HCPCS), and Workers' Compensation regulations.
• Strong analytical and critical thinking abilities.
• Proven ability to collaborate effectively with legal, compliance, and operational teams.
• Proficiency in Microsoft Office and bill review platforms.
• Detail-oriented with excellent organizational and time management skills.

Paradigm Benefits:

• Health and wellness- We want our people to be and stay healthy, so we offer PPO, HDHP, and HMO health insurance options with Cigna and Kaiser (CA employees only).
• Financial incentives - Paradigm's financial benefits help prepare you for the future: competitive salaries, 401(k) matching contributions, employer-paid life and disability insurance, flexible spending and commuter accounts, and employer-matched HSA contributions.
• Vacation - We believe strongly that work-life balance is good for you and for our company. Our paid time off and personal holiday programs give you the flexibility you need to live your life to the fullest.
• Volunteer time- We want our employees to engage with and give back to their communities in meaningful ways. Full and part-time employees receive one paid day per calendar year.
• Learning and development: One of Paradigm's core values is expertise, so we encourage our employees to continually learn and grow. We support this in a variety of ways, including our new Learning Excellence at Paradigm (LEAP) program.

Paradigm believes that fostering a diverse and inclusive workplace is central to our mission of helping more people and transforming lives. We're striving to build a culture that better reflects the society we live in and empowers our team to deliver the highest levels of compassion and care to those we serve. For us, achieving this goal requires a workforce that respectfully embraces differences and commits to positive change, creating an environment where everyone is able to bring their whole self to work.

Paradigm complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact Leave Management at leave.management@paradigmcorp.com.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

As a contractor with the State of Wisconsin, Paradigm complies with Wisconsin Contract Compliance Law (§16.765). Poster link: Contract Compliance Law Poster.

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