Sr Medical Review Specialist

Zenith Insurance Company (United States); Los Angeles (CA); On-site; USD 58,559 - 73,199; Full time

Benefits offered by this job

Medical, Dental and Vision Insurance

Flexible Spending Accounts

401(k), Employee Share Purchase Plan

Education and Training Reimbursement

Employee Assistance Program (EAP)

Job summary

A Workers’ Compensation Insurance provider in Los Angeles seeks a Medical Billing Auditor. The successful candidate will audit medical bills for accuracy, manage disputes with providers, and provide insights for process improvements. Strong communication skills and 3+ years of relevant experience are essential, along with a high school diploma. Benefits include comprehensive insurance, flexible spending accounts, and education reimbursement. This position offers competitive pay between $58,559 and $73,199, with opportunities for career growth.

Qualifications

• 3+ years experience reviewing progressively complex medical bills and records.
• Thorough understanding of the Workers’ Compensation billing process.
• Efficient in coding, negotiation, or another advanced specialty.

Responsibilities

• Audit medical bills for accuracy in coding.
• Manage caseload to resolve disputes with medical providers.
• Research billing issues and state regulations.
• Lead training initiatives on specialty topics.
• Identify and document trends in provider practices.
• Mentor and assist with training of junior analysts.

Skills

Advanced understanding of Workers’ Compensation claim billing

Strong verbal and written communication skills

Prioritization and time management skills

Flexibility and adaptability

Expert ability to communicate using industry language

Education

High School Diploma or equivalent

Bachelor’s Degree or equivalent

Job description

Zenith is a team of Workers' Compensation Specialists committed to helping businesses succeed by protecting against the financial and human consequences of workplace injuries, providing for the needs of injured employees and making the workplace safer. To distinguish ourselves as the desired provider of Workers' Compensation Insurance, values such as collaboration, work-life balance, and integrity are placed at the center of all our operations. In addition, Zenith supports career advancement through a dedication to ongoing learning and development. An individual coming to Zenith will not only receive competitive compensation and a comprehensive benefits package, but continuous opportunities to grow as a professional.

Overview

Under limited supervision, analyzes and audits medical bills from providers to determine appropriate reimbursement. Audits, analyzes, arranges and revises submitted information to determine reimbursement. Tracks issues and trends and makes recommendations for process documentation and technical improvements. Demonstrates an expert ability to provide or obtain complex information. As a subject matter expert, they coordinate and lead training on specialty topics.

Responsibilities

• Reviews and audits medical bills and re-evaluations from all states and jurisdictions to ensure accuracy in coding.
• Conducts timely and accurate processing of provider reconsiderations and/or resubmissions as assigned.
• May negotiate reimbursement on medical bills directly with providers and billing office personnel to settle open, unresolved medical services.
• Manages an assigned caseload to resolve outstanding disputes and liens from medical providers and other vendors for the purpose of cost savings and reductions for the company. Collects appropriate supporting documentation and works with or under the direction of a supervisor or manager to reach resolution.
• Identifies and seeks solutions to processes and/or systems issues impacting the team/department.
• Research billing issues, state regulations, Medicare billing rules and other coding entities. Collects documentation and submits for investigation per the Compass ticket process.
• May develop or work with management to develop appropriate metrics to monitor success of new solutions.
• Considers the impact of changes to workflows and communicates to supervisor and/or manager if changes or allocation adjustments are necessary.
• Leads initiatives to achieve adjustments to workflows as needed to improve process efficiencies and reduce overall costs.
• Serves as technical expert and main resource to Claims Examiners and Provider Dispute Resolution staff on state disputes or provider complaints. Researches and develops defensible responses to be submitted to the state.
• May also service as a resource to Attorneys on claims where the case in chief is active by addressing provider dispute issues to minimize exposure.
• Assists Bill Review Attorney and Compliance Specialist in gathering, reviewing, and summarizing documentation for defending appeals, petitions, and other disputes.
• May assist in representing the company before regulators.
• Demonstrates an expert ability to collaborate with vendors and providers to ensure they complete their contracted services and assists in monitoring processes and outcomes of vendors as needed/delegated.
• Participates in decisions regarding priorities, scope, and timeline for assigned projects.
• Identifies, documents, and collaborates with management regarding trends in provider and billing practices.
• Identifies changes needed in decision rules and communicates with supervisor and/or manager to improve efficiency of workflow.
• Mentors and assists with training of advancing Analysts in areas of increased complexity. May include preparation and/or development of training materials.
• Responsible for review of higher level, technical Workers’ Compensation bills, managing a diverse assignment that includes all types of medical and medical-legal services; including initial billing submissions, and re-evaluations/reconsiderations from single or multi- state jurisdictions, according to state fee schedules, guidelines, PPO network pricing and formal policies and procedures.
• Collaborate with Business Technical Team, Leads & Supervisors to propose, pilot and/or assist with workflow improvements.
• Work productively and harmoniously with others on a consistent basis.
• Respond positively to direction and feedback on performance.
• Apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
• Consistently maintain professional and appropriate demeanor.
• Performs other job related duties as assigned.

Qualifications Education

• High School Diploma or equivalent combination of education and experience required
• Bachelor’s Degree or equivalent combination of education and experience preferred

Work Experience

• 3+ years' experience reviewing progressively complex medical bills and records including multi-state and multi-jurisdictional required

Knowledge, Skills, And Abilities

• Thorough and advanced understanding of Workers’ Compensation claim billing process knowledge required
• Must demonstrate an expert ability to communicate proficiently using industry and regulatory language
• Must be efficient in at least one advanced coding pend, negotiation queue, or other advanced specialty
• Strong verbal and written communication skills
• Strong prioritization and time management skills
• Flexible and adaptable to a growing changing environment

Pay, Benefits, And Other Information

The expected salary range for this position is $58,559 - $73,199. Actual pay will be adjusted based on experience, geographic location, and other job-related factors as permitted by law. Qualifications may warrant placement in a different job level.

• Medical, Dental and Vision Insurance
• Flexible Spending Accounts
• Life, AD&D and Disability Insurance
• 401(k), Employee Share Purchase Plan (ESPP)
• Education and Training Reimbursement
• 10 paid Company Holidays, 2 Personal Days, 2 Floating Holidays
• Employee Assistance Program (EAP)
• For more information, review details on the Benefits page of our Career Site: https://www.thezenith.com/careers/benefits/

Zenith typically posts jobs for a minimum of 8 to 14 calendar days. If you are interested in any of our open positions, we encourage you to submit your application promptly.

Zenith Insurance Company is an equal opportunity employer and considers all qualified applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristic. In compliance with California law, we are committed to fair hiring practices. Pursuant to the California Fair Chance Act (AB 1008), we will consider qualified applicants with criminal histories in a manner consistent with the law. Additionally, in accordance with the Los Angeles Fair Chance Initiative for Hiring Ordinance, we will not inquire about an applicant’s criminal history until after a conditional offer of employment has been made.

If you are a qualified individual with a disability or a disabled veteran and need assistance accessing our career center or applying for a position due to your disability, you are entitled to request an accommodation. To make a request, please contact a Human resources representative at Zenith Insurance Company.