Medical Review Specialist - Examworks Group, Inc.

The Medical Review Specialist is responsible to create and write 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.

ESSENTIAL DUTIES AND RESPONSIBILITIES TO PERFORM THIS JOB SUCCESSFULLY INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:

• Receives client submissions and inputs client and examinee data in the system database.
• Sorts and verifies each claim contains all information required to conduct the review.
• Processes claims by correctly identifying the billing type (physician, surgery center, hospital, etc) and entering medical bills into the reviewing system, allowing automated adjudication to process.
• 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.
• Ensures all medical records and reports are properly documented and saved in the appropriate location and available for audit at all times.
• Processes client invoicing in accordance with the client’s fee schedule.
• Handles and responds promptly to incoming calls, emails or faxes from clients requesting report status and/or information.
• Provide notification to the Supervisor of any provider appeals and follow directions as given to resolve the claim.
• Responsible to inform management of any issues, concerns, updates or changes needed to a client’s profile, report of sale and/or client identification numbers.
• 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.

PROFESSIONAL COMPETENCIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

EDUCATION AND/OR EXPERIENCE  

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

CERTIFICATES, LICENSES, REGISTRATIONS  

Must possess one of the following current certifications: OASIS, RAC-CT or CCS. Based on business needs, certain units may require a specific certification in order to perform the role.

QUALIFICATIONS 

• Must possess one of the following current certifications: OASIS, RAC-CT or CCS. 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.

ABOUT US:

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, 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

ExamWorks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.