High Dollar Review Specialist

MagnaCare; Chapel Hill (NC); On-site; USD 70,000 - 100,000; Full time

Job summary

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high-dollar claims for accurate billing, pricing, and adjudication. This role supports the Quality Department and interfaces with multiple stakeholders.

The ideal candidate has significant facility-based billing experience, DRG expertise, and 3–5+ years in coding and claims examination, with strong communication and organizational skills.

Qualifications

• Significant experience in facility-based billing.
• Experience with physician/ancillary billings.
• Expertise in DRG Groupers.
• 3–5+ years coding and claims examination experience.
• Knowledge of Drug Reimbursement methods including AWP and J-codes.
• Familiarity with hospital billing systems and healthcare terminology.
• Excellent follow-up, organization and time management.
• Strong communication skills (written and oral).

Responsibilities

• Review high-dollar claims to ensure pricing and billing accuracy, including implant, supply, observation, and drug/procedure units.
• Review DRG for accuracy compared to billed procedures, diagnoses, and patient age.
• Develop reporting mechanisms to track high-dollar claims information.
• Collaborate with CMO, Legal, and other departments as needed.
• Coordinate efforts with external vendors as required.

Skills

DRG Groupers

Facility billing

Physician/ancillary billing

Coding & claims review

Drug reimbursement (AWP, J-codes)

Hospital billing systems

Communication skills

Follow-up & time management

Independent work

Job description

About The Role

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high dollar claims for appropriate and accurate billing, pricing and adjudication. This individual will play a key role in the Quality Department and interact with many internal and external stakeholders.

Primary Responsibilities

• Review high dollar claims to ensure claim was priced and billed correctly including implant and supply charges, observation room charges, units billed for drugs and procedures
• Review DRG for accuracy as compared to billed procedures, diagnosis/condition, age, etc
• Develop reporting mechanism to track pertinent claims information related to high dollar claims
• Collaborate review efforts with CMO, Legal and other departments as needed
• Coordinate efforts with external vendors as required

Essential Qualifications

• Significant experience in dealing with facility-based billing.
• Experience with physician/ancillary billings
• Expertise in DRG Groupers
• Candidate should have at least 3-5 years or more of coding and claims examination experience
• Working knowledge of Drug Reimbursement methodologies including AWP and ability to calculate J code reimbursements
• Familiarity with hospital billing systems and methodologies and healthcare terminology
• Impeccable follow up, organization, and time management skills
• Work well with all levels of management internally and externally also with the ability to work independently
• Confident, patient, work well with others, not afraid to ask question, open to learning
• Great communication skills (both written and oral)

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting‑edge third‑party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Come be a part of the Brightest Ideas in Healthcare.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.