Senior Workers' Compensation Compliance Analyst

Responsibilities

• Assist with reviewing state fee schedule rules, guidelines, regulations, and/or statutes for changes or compliance risks with reimbursement
• Draft second level reconsideration letters
• Assist with drafting and responding to state disputes
• Determine if the second level reconsideration request requires a medical coder or clinician for audit
• Work with the Director of Policy and Strategy Operations or the equivalent role to assist in implementing system changes for risk mitigation in Workers’ Compensation fee schedules or gap logic
• Provide consultation internally or externally where appropriate
• Provide internal training where required for compliance
• Assist in the development of compliance processes and procedures
• Partner with other business units to ensure compliance with implementing, adopting, or expanding on the rules and/or regulations, including but not limited to policies, procedures, and contracts
• Responsible for handling high level appeals – either based on the client or dollar threshold
• Establish special reimbursement policies for identified TIN’s
• Other duties as assigned or requested
• Responsible for handling negotiation with attorneys for state disputes

Requirements

• 5+ Years with current or former healthcare fraud, compliance, and/or legal experience.
• 3+ Years working with various medical reimbursement methodologies.
• 3+ Years understanding medical coding and/or billing patterns and/or practices.
• Knowledge of limited liability in property and casualty insurance
• Basic understanding of treatment parameters and coding
• Strong research skills
• Comfort with reading fee schedule rules, regulations, and statutes
• Strong oral and written communication
• Good judgment, initiative, and discretion in confidential or sensitive matters
• Self-starter with the ability to independently work urgently approaching deadlines and in a team
• Creative thinking and effective risk mitigation abilities with strong decision-making skills
• Strong analytical abilities
• Strong computer skills and experience with relevant software
• Excellent communication and presentation
• Strong critical thinking, analytical, and problem-solving
• Good interpersonal and organizational
• Strong written and oral communication skills.
• Intermediate or Advanced knowledge of Excel, Power Point, and Word.
• Hard Skills
• healthcare fraud
• compliance
• medical reimbursement methodologies
• medical coding
• billing patterns
• risk mitigation
• negotiation
• research skills
• analytical abilities
• decision-making
• Soft Skills
• strong oral communication
• strong written communication
• good judgment
• initiative
• discretion
• self-starter
• creative thinking
• problem-solving
• interpersonal skills
• organizational skills
• Industry Keywords
• fee schedule rules
• regulations
• statutes
• Workers’ Compensation
• compliance processes
• second level reconsideration
• high level appeals
• limited liability
• treatment parameters
• confidential matters
• Tools & Technologies
• Excel
• Power Point
• Word
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