Senior Workers' Compensation Compliance Analyst

Primary 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

Qualifications

• 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, PowerPoint, and Word.