Medical Bill Repricing Specialist (REMOTE w/in PA, NJ OR DE)

The Medical Bill Repricing Specialist is responsible for reviewing, evaluating, and processing workers' compensation medical bills to ensure accurate reimbursement in accordance with applicable state regulations, fee schedules, utilization review requirements, and company policies. This role performs bill review activities, researches and resolves billing issues, and communicates with medical providers, customers, and internal stakeholders regarding reimbursement determinations and claim status.

The Specialist is expected to consistently meet established productivity, quality, and service standards while completing all assigned tasks accurately and within designated timeframes.

Responsibilities

• Review workers' compensation medical bills and apply appropriate cost containment measures in accordance with jurisdictional requirements, workers' compensation regulations, utilization review guidelines, and company policies.
• Evaluate provider bills for completeness, accuracy, and eligibility for reimbursement by:
  • Verifying required billing information and documentation.
  • Identifying and resolving discrepancies or missing information.
  • Applying applicable reimbursement guidelines, fee schedules, and billing regulations.
  • Escalating complex or non-routine cases for technical review when appropriate.
  • Maintaining current knowledge of workers' compensation laws, regulations, and medical bill review processes.
• Contact medical providers, healthcare facilities, claim professionals, or other parties to obtain missing information needed to process medical bills accurately and timely.
• Enter and validate claim and billing information within the medical bill repricing system, ensuring data accuracy and completeness.
• Generate and review Explanation of Reimbursement (EOR) documents to verify reimbursement calculations and ensure appropriate payment rationale is communicated.
• Perform manual bill calculations and adjustments when automated pricing is unavailable or when special circumstances require additional review.
• Respond professionally and timely to inquiries from medical providers, customers, claimants, and internal business partners regarding claim status, reimbursement decisions, and bill review outcomes.
• Explain reimbursement determinations and applicable pricing methodologies to providers and customers as needed.
• Identify recurring billing, workflow, or system issues and recommend process improvements to enhance efficiency, accuracy, and customer service.
• Maintain confidentiality of claim and medical information and comply with all applicable privacy and regulatory requirements.
• Perform other duties and special projects as assigned.

Knowledge, Skills, and Abilities

• Knowledge of medical billing, coding, and reimbursement practices.
• Understanding of workers' compensation claims and medical bill review processes.
• Ability to analyze billing information and identify discrepancies.
• Strong problem-solving and decision-making skills.
• Ability to work independently while exercising sound judgment.
• Customer service orientation with the ability to handle provider and customer inquiries professionally.
• Proficiency in relevant computer systems and Microsoft Office applications.

QUALIFICATIONS

• High school diploma or equivalent.
• Minimum of two (2) years of experience in claims processing, medical billing, medical bill review, workers' compensation, healthcare reimbursement, or a related field.
• Strong attention to detail with the ability to accurately review, analyze, and process high volumes of work.
• Strong data entry and computer skills.
• Effective verbal and written communication skills.
• Strong organizational and time-management abilities.
• Ability to prioritize multiple tasks and meet established productivity and quality standards.
• Ability to interpret and apply policies, procedures, and reimbursement guidelines.

Preferred

• Experience with workers' compensation medical bill review or medical cost containment.
• Knowledge of utilization review principles and their application within workers' compensation programs.
• Familiarity with the Pennsylvania Workers' Compensation Bureau Utilization Review process.
• Understanding of medical terminology, CPT, HCPCS, ICD, and other procedure and diagnosis coding systems.
• Knowledge of medical fee schedules, reimbursement methodologies, and provider billing practices.