Bill Review Nurse Specialist - REMOTE - LVN/LPN/RN

EK Health Services Inc. is a leading national workers’ compensation managed care organization. EK Health partners with companies, insurers, healthcare professionals, and patients to successfully resolve and simplify the complex issues surrounding work comp healthcare. With a complete line of managed care solutions, EK Health sets the gold standard for early intervention, medical case management, utilization and peer review, medical bill review, network management, clinical specialty programs, preventative ergonomics, interpretation and translation, vocational rehabilitation, and medicare set-aside. Striving to transform the managed care industry, EK Health is focused on restoring quality of life for injured workers through innovative, cost-effective solutions. Clients trust us to provide services with high-touch experiences, customizable and nimble solutions, lower costs, and proven results. Our holistic approach integrates the best people, processes, and technology to facilitate the best medical treatment available for return-to-work possibilities.

Under the direction of the Bill Review Manager, the Bill Review Nurse Specialist is responsible for utilizing clinical acumen and medical review expertise related to reviewing workers’ compensation medical bills, including but not limited to: reviewing medical records, detailed/itemized statements and other documentation and applying medical necessity or payer guidelines to identify billed items and services that do not meet appropriate regulatory and compliance guidelines Position Specifics: Exempt-Full Time, Remote, Business Hours Monday through Friday

Accurately and appropriately analyze complex medical bills and make payment recommendations based on claim history, medical notes, usual and customary rates (UCR), statutory regulations including state laws and fee schedules, available MPN/PPO contracts, coding guidelines, client instructions, and company policies and procedures Research and apply applicable guidelines, and document clear and concise notes related to the recommendations along with related rationales Perform coding analysis. e.g. Medically Unlikely Edits (MUEs), Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT), Diagnosis Codes, etc. Engage with medical providers to negotiate medical services on behalf of our clients while creating long lasting relationships Communicate with medical providers to obtain needed information and resolve bill-specific issues Affidavits/Testify – Bill Review expert witness to provide expert testimony in legal cases involving medical billing disputes, or reasonableness of charges, particularly with insurance claims, workers’ compensation, personal injury, and medical malpractice. Review bills with missing Codes. Review corresponding medical documentation and provide appropriate billing. Medical Records – Able to review medical records Explanation of Review (EOR) – Provide EORs that include detailed sources to complete an analysis. Matching Diagnostic Codes with Bills – Able to match diagnostic codes to codes on a bill Respond to issues and drive problem resolution in a quick turn- around time Participate in ongoing training to enhance job skills and knowledge Maintain emphasis on privacy and confidentiality in all review interactions and completions Complete assigned cases accurately, meeting all regulatory and compliance timelines Continuous working knowledge of Ahshay and the BR system Support and assist all levels of the organization Other duties as assigned