Pricing Resolution Specialist

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MedReview Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

⚕️ Healthcare Insurance

💸 Finance

Healthcare Insurance • Finance

MedReview Inc. is a leading provider of advanced payment integrity solutions, specializing in healthcare claims. They work with a wide range of clients, including health plans, government agencies, and payors, to reduce unnecessary waste and save billions of dollars. Their team of highly trained physicians, registered nurses, and certified coders conduct thorough clinical and coding reviews to identify inaccuracies in healthcare claims. MedReview employs proprietary algorithms to analyze complex data and detect suspicious payment trends, offering a unique blend of clinical expertise and advanced technology to maximize efficiencies and improve healthcare cost management.

📋 Description

• 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.

🎯 Requirements

• 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.