Scope: The Concierge Healthcare Bill Analyst, via the Healthcare Bill Analysis (HBA) system, reprices and analyzes assigned healthcare bills and assists other non-clinical MedWatch personnel by providing information used in provider negotiations and appeals. Education: • Bachelor’s degree in a health-related field preferred. Licensure/Certification Requirements: • Registered Nurse (current active and unrestricted, in state of current practice and residence, within the United States or its territories.) Experience: • Minimum of 2 years of inpatient hospital experience OR 2 years of experience as a Clinical Documentation Specialist or Recovery Audit Contractor Specialist. Requirements/Skills: • Strong computer skills with proficiency in MS Office Suite products (Word, Excel, PowerPoint) • Coding and DRG experience preferred. • Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs preferred. • Understanding of hospital coding and billing rules. • Adequate clinical skills to evaluate healthcare bills. • Comprehension of hospital coding, billing guidelines and regulations includes but not limited to Medicare • Highly organized with attention to detail • Bilingual; English and Spanish is a plus. Duties and Responsibilities: • Analyze healthcare bills based on accepted billing and coding rules, Medicaid, CMS (Centers for Medicare/Medicaid) guidelines, and established clinical guidelines. • Validates the accuracy of UB-04 and CMS 1500 claim billing and identifies billing errors, as well as provider billing practices that are concerning such as potential for overutilization, fraud/abuse, or patterns of repeated errors. • Perform repricing of outpatient and inpatient facilities as well as professional bills. Alongside and following a training program, you will be expected to keep abreast of coding and billing guidelines. • Analyze itemized bill for medical appropriateness and billing inconsistencies by performing a line-by-line clinical review of a claim. • Performs analysis of Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT) and Diagnosis Codes utilizing current coding and reference tools. • Reviews CPT codes for unbundling, multiple procedures, inappropriate modifiers, etc. • Serve as a clinical resource to Concierge Team and Member/Provider Inquiries/Appeals. • Underwriting assistance to estimate treatment cost, possibly reviewing medical records. • The incumbent may be responsible for duties or responsibilities that are not listed in this job description. Duties and responsibilities may change at any time with or without notice. Work Environment / Physical Demands: This position is in a typical office / home office environment which requires prolonged sitting in front of a computer. Requires hand-eye coordination and manual dexterity sufficient to operate standard office equipment including operation of standard computer and phone equipment. E.O.E.
Are you ready to take your career to the next level? At MedWatch, we are a community of passionate, driven individuals who thrive on innovation and collaboration. For over 35 years, MedWatch has partnered with clients to develop innovative and effective solutions to address their needs. By mitigating risk within the plan population and focusing on quality care and improved outcomes, MedWatch reduces healthcare expenditures for the plan and plan member. We offer competitive compensation and a comprehensive benefits package including Paid Time Off, Medical, Dental, Vision, Short and Long-Term Disability, Life Insurance, AD&D, 401k with match, critical illness coverage, and discount programs.
