This job can be filled in any of our Zenith Branches with preference in our Orange, CA or any other CA Branch Office
There are 2 open positions
Utilizes high-level critical thinking skills to perform clinical review, analysis and adjudication of select bills based on workers' compensation fee schedules or other jurisdictional pricing, and to provide medical cost projections. Partners with claims, medical management and legal staff for holistic claims handling. May involve assisting with special projects.
The essential functions of this position include, but are not limited to, the following:
Audits and analyzes medical bills and records from multiple states to verify, adjust, and recommend fair and reasonable reimbursement in accordance with state fee schedules, coding guidelines, healthcare regulations and medical compliance.
Utilizes multiple comparative pricing tools to assist with determining fair and reasonable reimbursement, while relying on clinical expertise to analyze the reasonableness of medical care coupled with strong critical thinking skills to strategize various payment methodologies.
Uses independent judgement and considers state fee schedules and various other pricing methodologies to prospectively and retrospectively negotiate with providers on select high dollar bills and services.
Collaborates with bill review legal to establish fair and reasonable reimbursement and partners with claims staff, compliance, legal, and dispute team to respond to disputed payments and state appeals.
Responds to referrals from claims examiners and internal nurse case managers, including provision of cost projections for surgeries and various other treatment, as well as coding reviews to assist with the pre-authorization of medical care and setting of claim reserves.
Reviews medical records to evaluate the treatment rendered for medical necessity and refer for peer review when applicable.
Assists management in identifying areas of opportunity based on current medical billing environments.
Serves as a resource for special projects, training, and reports.
Performs other job related duties as assigned.
Education, Skills and Experience Requirements
Active and clear health professional license. RN preferred but will consider other para-professional with extensive, relevant coding and bill auditing experience.
3-5 years (minimum) of clinical experience.
Preferred - utilization/bill review, claims, managed care processing; workers compensation bill audit experience, including knowledge of workers compensation laws/fee schedules in most states
Experience with/understanding of utilization/bill review, claims, managed care processing
Excellent negotiation, problem solving and analytical skills and strategies.
Excellent interpersonal and communication skills oral and written. Must be able to communicate effectively with all levels of staff.
Experience with Windows (3.1 or higher), Microsoft Office, and Excel.
Qualifications may warrant placement in a different job level*
Zenith Insurance Company