Team Lead, Inpatient Claims Pricing Specialist

Position Summary

At MedReview, our mission is to bring accuracy, accountability and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews.

Pricing and analysis of inpatient medical claims utilizing NYCHSRO/MedReview and payer specific systems, adjudication platforms, policies, and procedures. Provide support to various departments related to claim status, claim adjudication questions, and any basic questions related to the adjudication of an inpatient medical claim.

Candidate should be highly motivated, with strong pricing background including experience in platforms such as Facets, Webstrat, and Encoder. This individual must have excellent communication skills, must be analytical, have strong problem solving skills, and have the ability to make quality decisions.

This is a fulltime position (40 hours per week) Monday – Friday. You’ll enjoy the flexibility to telecommute from anywhere within the United States. Training will be conducted virtually from your home.

Responsibilities:

This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of MedReview Operations in general.

• Serves as a knowledge expert and maintains up to date working knowledge of pricing guidelines in order to act as a resource for all pricing team members.
• Responsible for reviewing data in the review application and client claim processing system, and comparing with corresponding UB, medical record or other documentation
• Responsible for reviewing all necessary documentation as necessary to determine appropriate reimbursement for a claim
• Responsible for reviewing adjudication software system’s claim and line items for determination of how to price a claim / line item
• Possess ability to work at a computer for extended periods
• Performs quality reviews on individual team members ensuring all claims are completed timely and per department standards
• Identifies education needs within the department to facilitate pricing accuracy improvement
• Works collaboratively with Assistant Director of Pricing to analyze and optimize processes to maintain acceptable productivity rates for each individual team member
• Works collaboratively with Assistant Director in developing educational tools for new hire orientation and ongoing department education
• Other duties as assigned
  
  

Qualifications:

• Associates degree preferred.
• Minimum of 5 years management experience
• Minimum of 5 years related work experience. Prior experience with claim adjudication systems, grouping and pricing software, and other claim adjudication and claim pricing systems. Ie; Facets, Cosmos, CAS, WebStrat, Encoder
• Experience with pricing reject resolution
• Basic knowledge of medical terminology.
• Good knowledge of Microsoft Word, Excel and Outlook
• Intermediate mathematics aptitude
• Good communication skills
• Good organizational abilities
• Good comprehension capabilities
• Ability to prioritize multiple tasks
• Experience with UB/institutional claims
• Knowledge of Medicare and Medicaid billing & payment and coverage guidelines
• Strong experience in the analysis and processing of claims, quality assurance, CMS payment methodologies (i.e., DRGs, Cost Outliers)
• Must be able to work with minimal supervision
• Creative thinker with good skills at problem resolution specifically related to healthcare claim adjudication
• High speed internet (300 Mbps per person recommended) with secured WIFI
  
  

Benefits and perks include:

• Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents
• 401(k) with Employer Match - Join the team and we will invest in your future
• Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays
• Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered
• Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional
  
  

Salary: 65k- 75k

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