Apply on Employer Site

Paradigm · 1 week ago

Bill Review Specialist Lead

Tampa, FL, USA

Full-time

Hybrid

Senior Level

$24/hr - $32/hr

5+ years exp

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. They are seeking a Bill Review Specialist Lead who will provide senior-level support for provider bills and appeals research, leading complex projects and ensuring compliance with regulatory requirements.

Health CareHospitalMedical

Responsibilities

Receive, research, coordinate, and resolve incoming bills, appeals, or client inquiries, payment questions, and issues with internal team members, providers, or clients, as appropriate

Assist in reducing rework by identifying and remediating billing, appeals, and client processing issues

Use advanced analytical skills to conduct research and analysis for issues, requests, and inquiries on high priority claims/appeals projects

Evaluate processed provider payments data using standard principles and applicable state-specific policies or agreements (e.g., Single Case Agreements) to identify reimbursement or billing processing errors

Customize existing reports or available data to meet the needs of claims projects

Act as a senior provider reimbursement subject matter expert, advising on complex billing issues and ensuring compliance with regulatory and contractual requirements

Lead and manage major provider payments research projects of considerable complexity, initiated through provider or client inquiries or internal requests

Conduct advanced root-cause analysis to identify and resolve systemic bill processing errors, collaborating with multiple departments to define and implement long-term solutions

Interpret regulatory and contractual requirements to ensure compliance with provider payments (claims) or appeals adjudication and remediation processes

Develop, track, and/or monitor remediation plans, ensuring provider reimbursements (claims)/appeals reprocessing projects or inquiries are completed accurately and on time

Conduct periodic audits of provider payments and appeals processed by the team to ensure accuracy, compliance, and proper reimbursement, while maintaining a collaborative approach

Proactively identify and recommend updates to policies, SOPs, and job aids to improve claims quality and efficiency

Collaborate with internal stakeholders and leadership to define provider reimbursement and appeals requirements and ensure alignment with organizational goals

Assist in processing appeals and reconsiderations

Qualification

Medical claims processingRegulatory complianceProject managementComputer skillsHealthcare billing knowledgeReasoning abilityOrganizational skillsOral communication skills

Required

Education – High School Diploma or equivalent required

Experience - 5+ years in worker's comp and/or in medical claims processing, research, or a related field (Managed Care Organization – Medicaid, Medicare, Commercial). Project management

Intermediate computer experience using Microsoft Word, Excel & Outlook required

Excellent organizational skills

Language Skills - Excellent oral communication skills and phone presence. Ability to effectively tailor complex information for diverse audiences, including providers and executive leadership

Reasoning Ability – Proven ability to manage multiple projects, prioritize tasks, and meet tight deadlines in a fast-paced environment

Preferred

Bachelor's Degree or equivalent combination of education and experience

Knowledge of Worker's Comp; Healthcare billing; ICD-9 or ICD-10; CPT; RVS; U&C; Fee Schedule; HCPCS & other coding schemes

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.