Casualty Bill Review Specialist

About The Role

The Casualty Bill Review Specialist is responsible for ensuring accurate, compliant, and efficient medical bill review within the New York workers’ compensation and casualty environment. This role serves as a subject matter expert (SME) in New York and other state regulations, partnering closely with Network, Operations, and cross-functional teams to ensure proper configuration of bill review processes, rules, workflows, and pricing implementation. The Specialist is also responsible for training interdepartmental staff on applicable rules, policies, procedures, and regulatory requirements.
*This is a remote role.

Primary Responsibilities

• Bill Review & Regulatory Compliance:
  - Review medical bills for accuracy, coding validity, and compliance with New York Workers’ Compensation Board (WCB) regulations.
  - Apply New York Medical Treatment Guidelines (MTGs).
  - Ensure proper application of New York fee schedules and reimbursement methodologies.
  - Evaluate medical narratives and attachments.
  - Ensure compliance with prompt payment requirements.
• Rules, Workflow & Pricing Management:
  - Configure and maintain bill review rules and workflows.
  - Partner with Network and Operations for pricing implementation.
  - Monitor system outputs and recommend improvements.
• Cross-Functional Collaboration:
  - Collaborate with Network, Operations, IT, and vendors.
  - Ensure alignment of bill review strategies and processes.
• Training & SME Responsibilities:
  - Serve as SME for New York bill review.
  - Develop and deliver training programs.
  - Create job aids and documentation.
• Disputes & Compliance:
  - Collaborate with team members on denials, reconsiderations, and dispute processes.
  - Ensure WCB compliance and audit readiness.

Essential Qualifications
-At least 5 years of demonstrated expertise of New York MTGs 
- Expertise in NY fee schedules and reimbursement methodologies
- Knowledge of CMS-1500 EDI billing
- Understanding of medical narratives and attachments
- Experience with WCB dispute processes
- Strong knowledge of CPT, HCPCS, ICD-10 coding
- Familiarity with Medical Necessity forms and Authorizations
- Understanding of NY billing regulations and PAR processes
- Ability to review bills for compliance
- Knowledge of DME, Home Health, and Ancillary reimbursement
- Understanding of prompt payment requirements

 

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

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