High Dollar Review Specialist

About the Role Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high dollar claims for appropriate and accurate billing, pricing and adjudication. This individual will play a key in the Quality Department and interact with many internal and external stakeholders. Primary Responsibilities Review high dollar claims to ensure claim was priced and billed correctly including implant and supply charges, observation room charges, units billed for drugs and procedures. Review DRG for accuracy as compared to billed procedures, diagnosis/condition, age, etc. Develop reporting mechanism to track pertinent claims information related to high dollar claims. Collaborate review efforts with CMO, Legal and other departments as needed. Coordinate efforts with external vendors as required. Essential Qualifications Significant experience in dealing with facility-based billing. Experience with physician/ancillary billings. Expertise in DRG Groupers. Candidate should have at least 3-5 years or more of coding and claims examination experience. Working knowledge of Drug Reimbursement methodologies including AWP and ability to calculate J code reimbursements. Familiarity with hospital billing systems and methodologies and healthcare terminology. Impeccable follow up, organization, and time management skills. Work well with all levels of management internally and externally also with the ability to work independently. Confident, patient, work well with other, not afraid to ask question, open to learning. Great communication skills (both written and oral). #J-18808-Ljbffr Brighton Health Plan Solutions