Workers’ Compensation Specialist NEW

Reading, Pennsylvania
The Judge Group

Job Summary and Qualifications:

This position is responsible for the initial screening, evaluation, some on-line error and entry correction of workers’ compensation medical bills. When information needed to process the medical bill is incomplete, this position is responsible for telephoning the appropriate party to collect the relevant information. The position will handle calls from medical providers and internal and external customers regarding the status of the bill or the amount of reimbursement.

Responsibilities:

1. Reviews all medical bills brought to his/her attention for the application of cost containment measures. This is to be completed according to the jurisdictional requirements of the workers compensation law and involved both medical bill cost containment and utilization review for three (3) jurisdictions.
2. Screens and evaluates bills for provider services. This includes: determining if all billing information is complete and correct; obtaining by telephone follow-up, and evaluating any missing information in order to process the bill; applying all relevant guidelines that pertain to the evaluation of reported services; obtaining technical assistance for highly specialized non-routine decisions, as warranted; and maintaining and applying a current knowledge of those aspects of workers’ compensation laws and regulations that affect medical bill processing.
3. May key claim data into the medical repricing system and produces and Explanation of Reimbursement (EOR); the system prices the claim based on reported medical procedures diagnosis and location of provider. For some claims, manual processing is required by using simple tables and lists. The incumbent is responsible for verifying data for accuracy of entry and reasonableness of results, and printing EOR for each claim. The incumbent must select multiple possible statements to appear on the EOR.
4. Responds to telephone inquiries from providers, internal and external claimants and customers, as needed. The incumbent answers questions as to why reimbursement was made at a particular level (level of reimbursement made by the system).

Qualifications:

High School diploma or equivalent required

Minimum of 3 years of experience in workers compensation claims processing.

In-depth knowledge of utilization review and its various applications and Pa. W.C. Bureau’s Utilization Review process required.

Excellent procedure code knowledge, medical cost containment knowledge, good data entry skills and the ability to apply pertinent policies in evaluating and handling medical bills and cost containment at all levels of complexity.

The incumbent must be courteous in dealing with various parties via telephone, and must in addition be able to instruct others in medical cost contain