Claim, Nurse - Medical Case Manager

Compensation Overview

The annual base salary range provided for this position is a nationwide market range and represents a broad range of salaries for this role across the country. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. As part of our comprehensive compensation and benefits program, employees are also eligible for performance-based cash incentive awards.

Salary Range

$65,300.00 - $107,600.00

2

Under general supervision this position is responsible for examining and evaluating previously paid complex surgical bills based on additional medical records submitted by medical providers to ensure proper reimbursement under the WC statute for all 50 states. Responding to escalated calls from medical providers regarding payment decisions for surgical services. Providing Medical Provider Appeals Analysts with expert technical support for most complex medical issues. Responsible for keeping abreast of medical rules, procedures, regulations and contracts that are continuously changing in a fast pace, highly technical medical environment.

What Will You Do?

• Perform a detailed review of previously submitted complex surgical services bills along with accompanying reports/information for accuracy and to determine appropriateness.
• Partner with Claim Professionals to properly analyze and determine formal responses to WC legal Medical Bill Disputes.
• Using multiple screens on the Medical Bill Re-pricing System, read and interpret scanned complex surgical reports to determine that procedures on bill were actually performed and coded to reflect the services that were actually provided.
• Compare bill and rates with appropriate fee schedule rules, clinical edits, and Medicare, National Correct Coding Initiative (NCCI), internal Travelers protocols and PPO contracts to determine whether additional payment is due or if recovery of overpayment is necessary.
• Compile surgery, anesthesia, and co-surgeon, assistant, and hospital bills to determine if there is overlap or duplication of any services and that appropriate.
• Diagnosis Related Grouping (DRG), coding, trauma, and implantable surgical devices are used.
• Identify each instrumentation item used and re-price using invoices or data base.
• Apply payment policies to medical supplies and drugs/ medicine.
• Make accurate payments to medical providers based on the results and analysis of each medical bill.
• If original decision will be upheld, develop a formal response with supporting documentation. Commence recovery measures, when overpayment has occurred.
• Serve as the liaison between the provider and company including department leadership, Travelers Claim Product team and third party vendors.
• Regularly and independently identify and bring to managements attention any unusual/new medical or surgical procedures or billing anomalies identified during the review.
• In addition to day-to-day responsibilities, participates on high volume special projects in support of the New Product team.
• Deliver superior customer service to Travelers Claim professionals and those medical providers with escalated issues. Answer questions and analyze and resolve problems.
• Provide expert medical advice to Medical Provider Appeals Analysts. Assist management by providing mentorship and training to raise the overall level of medical proficiency.
• Perform other duties as assigned.

What Will Our Ideal Candidate Have?

• Nursing degree and /or equivalent work experience preferred.
• Nursing Orthopedic surgery experience, a plus.
• Ensure that quality of transactions follows Travelers SLA quality standards.
• Solid customer service telephone skills.
• Strong interpersonal communication skills.
• Strong verbal and written communication skills, including effective sentence construction, grammar, spelling, and punctuation. Basic computer skills: ability to toggle between screens to find data that is needed to process medical bills.
• Proficiency in Microsoft Office products (e.g. Excel, PowerPoint, Word, Outlook)Must have excellent working knowledge of human anatomy & medical terminology.
• Working knowledge of Workers Compensation processes and procedures including fee schedule and payment rules preferred.
• Solid math skills: must be able to quickly and accurately add, subtract, multiply and divide with the assistance of a calculator.
• Proven ability and interest in staying abreast of new and emerging surgical trends and literature.
• Strong attention to detail and ability to independently reads and comprehend completely the details of a surgical operative report and notes and assess them against all appropriate rules and protocols.
• Must have proficient knowledge of medications and dosages. Able to identify medication as to whether it is a capsule, pill, inject able, intrathecal, or topical.
• Proven ability to effectively coach and mentor co-workers with less medical knowledge.
• Strong comprehension, time management, and analytical skills.
• Ability to produce high quality results in a high production environment.
• Superior Organizational Skills and Attention to Detail.
• Commitment to Task.
• Continuous Learning.
• Decision Making and Problem Solving skills.
• Decisiveness.
• Sense of urgency.
• Flexibility.
• Nursing or commensurate experience with the following resource materials:
• Current Procedural Terminology (CPT)
• International Classification of Diseases-9 Revision (ICD-9)
• Healthcare Common Procedural Coding System- 9th Revision (HCPCS) codes
• Itemized hospital bills, hospital records.
• Certified California Medical Bill Reviewer a plus.
• Able to interpret very complex and unusual coding and procedures.
• Certified California Medical Bill Reviewer, a plus.

What is a Must Have?

• Registered Nurse or Licensed Practical Nurse with Surgical clinical experience.