Director of Specialty Bill Review Services - Remote

As our Director of Specialty Bill Review Services, you will maximize savings and client satisfaction by providing strategic direction for Rising’s Specialty Services unit involving complex/large medical claims; analyzing and optimizing bill review procedures and systems; and leading a team of experienced medical bill review auditors, nurse auditors, med-legal nurse, negotiators and related staff in an environment of continual performance improvement.

Here's What You'll Be Doing

• Act as Operations SME for capturing savings and fee allocation to optimize revenue.
• Participate in ongoing training to enhance own job skills, knowledge, and professional growth. Keep informed on issues and trends relating to Healthcare, Workers Compensation, Bill Review, Cost Containment, Managed Care, and related areas.
• Collaborate with other members of Rising’s management team to support core values and achieve company objectives.
• Monitor changes in State and Federal laws, rules or fee schedules that impact medical bill review/re-pricing and ensure they are integrated into workflows (and Smart Advisor via Mitchell) for proper adjudication.
• Help develop medical bill re-pricing guidelines and procedures to address any legal ambiguities, or situations where no applicable rules or fee schedules exist.
• Work with Tech Operations to help develop system rules/automation that reduce and minimize manual processes.
• Manages/oversees Test Bills for prospective clients to maximize savings.
• Participate in prospective client presentations.
• Research and build a library of case law (particularly regarding state-specific jurisdictional workers compensation issues) that can be drawn from to assist in provider negotiations and to defend company medical bill re-pricing decisions.
• Prepare legal/settlement assessments, manage litigation/bill disputes, respond to defense attorney requests, and provide testimony as an expert witness as required.
• Research and answer complex questions regarding CPT, ICD-9, HCPC and other codes, fee schedules, PPO applications, and other technical matters. Resolve errors as needed.
• Provide world-class customer service by promptly answering inquiries and questions from Rising staff and clients.
• Special projects as assigned by executive management

Requirements

• College degree required, with an emphasis in finance, business, or operations.

• CPC (Certified Professional Coding) certification or equivalent required

• Minimum five years of financial analysis/business, medical claims adjusting background preferably in Workers Compensation with progressive management responsibility.

• Experience in medical bill review, CPT coding, and cost containment strongly preferred.

• In-depth understanding of Workers Compensation rules and regulations required.
• Supervisory and managerial skills—able to bring out the best in others
• Strong oral and written communication skills
• Strategic thinker with an ability to translate plans into action
• Ability to understand complex issues, identify opportunities, and recommend appropriate solutions
• Excellent project manager
• Technical knowledge of healthcare billing procedures, documentation, and standards
• Thorough understanding of the complex inter-relationships between CPT codes/modifiers, ICD-9 codes, HCPCS codes and medical terminology
• Ability to research, interpret, catalog, and retrieve case law
• Analytical, problem solving, and decision-making abilities
• Ability to organize resources and establish priorities
• Proven customer service skills, including the ability to calmly deal with potentially intimidating attorneys and medical providers
• A desire to continue to learn and improve both self and the organization

Benefits

• A relaxed, yet upbeat, work environment with a jeans professional dress code
• Generous Flexible Time Off (take it when you need it!)
• Competitive base salary, benefits, 401k matching, and more!
• Career Growth Opportunities (we often promote from within!)
• Daily interaction with some of the most talented people in the medical cost-containment industry
• Rising was named a Top Workplace in the healthcare industry for 2023! Check out our profile here: Rising Medical Solutions Profile (topworkplaces.com)
• We're on YouTube! Check out our culture at: (48) RisingMedical - YouTube
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• Facebook: Rising Medical Solutions | Chicago IL | Facebook
• LinkedIn: (29) Rising Medical Solutions: My Company | LinkedIn
• Glassdoor: glassdoor.com/Overview/Working-at-Rising-Medical-Solutions-EI_IE322608.11,35.htm