The Role
The Pricing Resolution Specialist analyzes inpatient medical claims, reviews documentation for reimbursement, and provides support on claims adjudication issues.
Summary Generated by Built In
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.
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.
Qualifications:
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.
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.
- 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.
- Other duties as assigned.
Qualifications:
- High School Diploma or Equivalent
- 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.
- Basic knowledge of medical terminology.
- Good knowledge of Microsoft Word, Excel and Outlook
- Intermediate mathematics aptitude
- Basic communication skills
- Proficient organizational abilities
- Proficient comprehension capabilities
- Ability to prioritize multiple tasks
- Experience with UB/inpatient institutional claims
- Proficient 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
Skills Required
- High School Diploma or Equivalent
- Minimum of 5 years related work experience
- Prior experience with claim adjudication systems
- Basic knowledge of medical terminology
- Good knowledge of Microsoft Word, Excel, and Outlook
- Intermediate mathematics aptitude
- Basic communication skills
- Proficient organizational abilities
- Proficient comprehension capabilities
- Experience with UB/inpatient institutional claims
- Strong experience in the analysis and processing of claims
- Knowledge of Medicare and Medicaid billing & payment and coverage guidelines
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The Company
What We Do
MedReview is a physician-led healthcare services company and a leading authority in payment integrity solutions, offering auditing, utilization management, and clinical reviews to ensure accurate claims processing.
