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Telephonic Case Manager Medical Bill Reviewer

Remote, US

TCM Medical Bill Reviewer

 

Our Story

Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.

 

What’s in Store 

We're on the lookout for a Telephonic Case Management Medical Bill Reviewer. As a TCM Medical Bill Reviewer, you will review Workers’ Compensation provider medical bills via the system for cost containment purposes. You will also analyze, review and process Workers’ Compensation medical bills for payment according to state Workers' Compensation fee schedule and beyond. Additionally, you will recommend payment to medical providers, hospitals, ancillary medical providers, rehabilitation services and pharmacies and other services according to the Davies North America State of Florida Program Bill Authorization process and significantly reduce costs to clients. Additional responsibilities include:

 

  • Utilizing medical expertise and knowledge of the UR process, ICD-10 coding, HCFA billing, CPT and CHPCS coding, review of medical bills for appropriateness of codes and fees, while ensuring they are in compliance with state fee schedules and agreements
  • Review of complex HCFA bills to determine authorization, relation to injury and appropriateness of service
  • Review of complex UB bills to determine authorization, relation to injury and appropriateness of service 
  • Appropriately document all activities, including attachment of emails and records in the computerized system
  • Create, edit and/or revise correspondence as necessary
  • Utilize problem solving skills to identify questionable claims and/or trends during the bill review process.
  • Meet all expectations outlined in the policy and procedure for State of Florida criteria and Davies North America standards for peer review
  • Maintain patient privacy by ensuring that all medical records, case specific information and provider specific information are kept in a confidential manner, in accordance with state and federal laws and regulations
  • Accurately complete provider bill reviews according to Davies North America State of Florida Policies and Procedures in the computer system, according to state Workers’ Compensation Fee Schedule rules, with satisfactory volume and error ratio
  • Analyze, review and recommend payment to medical providers based upon statutory rules or guidelines and/or provider reimbursement contract amounts to achieve maximum cost savings, to the level appropriate in terms of: 
    1. Proper Billing Form
    2. Medical necessity
    3. Treatment actually …
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