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Paradigm · 23 hours ago

Provider Appeals & Legal Liaison

United States

Full-time

Onsite

Senior Level

$80K/yr - $105K/yr

7+ years exp

Paradigm is seeking a Provider Appeals & Legal Liaison responsible for leading the interface between the Medical Bill Review/Claims team and the Legal department. This role manages complex medical provider appeals, supports legal responses to billing disputes, and ensures compliance with Workers’ Compensation regulations.

Health CareHospitalMedical

Responsibilities

Act as the primary liaison between Medical Bill Review / Complex Claims and Legal on repricing disputes, state filings, provider appeals, and reconsideration matters

Lead the review, analysis, and resolution of high-complexity provider appeals and billing reconsiderations within the healthcare and payor sector

Exercises sound judgment in handling the provider appeals and billing reconsiderations responses

Draft and refine written responses to providers and legal teams, ensuring clarity, accuracy, and defensibility

Collaborate with Legal on dispute resolution strategies, regulatory filings, and litigation support

Comfortable reviewing legal documents related to provider disputes and escalating to legal or requesting additional legal guidance as necessary

Maintain expert-level knowledge of Workers’ Compensation fee schedules, coding standards, and bill review methodologies

Identify trends in provider disputes and recommend proactive solutions or process improvements

Represent Medical Bill Review in cross-functional meetings and initiatives involving Compliance, Provider Relations, and Network Development

Ensure accurate documentation of case activity and maintain audit-ready records

Support internal training and knowledge-sharing on medical bill review best practices and legal coordination

Special projects as assigned

Responsible for complying with Paradigm Information Security requirements and policies, for safeguarding Paradigm or Paradigm related passwords, and for notifying Paradigm of any Information Security incidents per policy SEC 10-12 Information Security Incident Management

Qualification

Workers’ Compensation expertiseMedical billing knowledgeLegal coordination experienceAnalytical skillsMicrosoft Office proficiencyCommunication skillsDetail-orientedOrganizational skillsTime management skillsCollaboration skills

Required

Bachelor's degree or equivalent experience required; advanced coursework in healthcare administration, legal studies, or medical billing preferred

Minimum 7 years of national Workers' Compensation bill review experience, with at least 3 years in a role involving appeals, reconsiderations, or legal coordination

Excellent written and oral communication skills and phone presence. Ability to effectively present information to providers as well as to employees of the organization

Advanced understanding of medical billing, coding (ICD-10, CPT, HCPCS), and Workers' Compensation regulations

Strong analytical and critical thinking abilities

Proven ability to collaborate effectively with legal, compliance, and operational teams

Proficiency in Microsoft Office and bill review platforms

Detail-oriented with excellent organizational and time management skills