Senior Complex Bill Reviewer 2

The Enlyte Family of Businesses

Mitchell | Genex | Coventry

Enlyte is the parent brand of Mitchell, Genex and Coventry, an organization unlike any other in the Property & Casualty industry, bringing together three great businesses with a shared vision of using technology innovation, clinical services and network solutions to help our customers and the people they serve. Our suite of products and services enable our employees to help people recover from challenging life events, while providing opportunities for meaningful impact and career growth.

This is a full-time, remote position. Candidate will work Eastern/Central Time Zone schedule.

Must have an active RN, LPN, or LVN license in good standing.

As a Senior Complex Bill Reviewer, you will apply clinical knowledge to assess medical bills against medical records to ensure appropriateness of coding and billing and level of service in Workers Compensation cases requiring retrospective review. You will be responsible for reviewing and analyzing information to make payment determinations based on established policies and guidelines and integrated evaluation of specific billing circumstances. In this role, you will:

• Conduct medical reviews of individual provider, hospital bills, specialty claims and adjustments for coding and billing accuracy and to ensure compliance with company policies and procedures and state guidelines
• Review documentation to identify unsupported or incorrectly billed codes
• Audit of complex medicals bills and a variety of insurance claims: workers compensation, auto, liability
• Use independent judgment and clinical knowledge to adjust bill payment as appropriate to comply with company policies
• Identify and recommend opportunities for bill reductions to enhance client cost management outcomes
• Process and/or review claims for compliance in a timely manner that meets or exceeds production and quality goals
• May serve as subject matter expert or training resource for team, identify training opportunities and assist with complex questions regarding review process, code review, and determination of appropriate courses of action to resolve escalated issues

• Registered Nurse (RN), License Practical Nurse (LPN), Licensed Vocational Nurse (LVN) with active state license in good standing in the state where job duties are performed. Required
• Registered Nurse Certified Professional Coder Plus
• 3-5 years clinical experience, particularly in Operating Room/Implants, Emergency Room, and specialized areas
• Proficiency in medical coding (CPT, HCPCS, ICD-10) and billing guidelines
• Previous experience in medical claim review, workers compensation, case management, utilization review, auto liability, and orthopedics preferred.
• Experience with electronic medical records and bill review platforms (Smart Advisor Plus preferred)
• Performance Metrics related to bills per hour and quality scores (Payment, Procedural, Financial Accuracy)
• Excellent verbal and written communication abilities
• Strong analytical, problem-solving, and decision-making skills
• Demonstrated ability to work independently on project assignments.
• Proficiency in Microsoft Office suite and adaptability to proprietary software

PI267908377