<p>Paradigm is seeking a full-time, benefitted Claims / Bill Review Quality Program Lead. The ideal candidate would be located in the Tampa, FL, area and be willing to work hybrid (1-2 days per week in office and the rest working from home), but other candidates will be considered. The schedule is Monday through Friday, regular business hours.</p> <p>The Claims / Bill Review Quality Program Lead position holds accountability for execution and oversight of the quality control, quality assurance and continuous education for the Complex Bill Review department. The position ensures superior performance of all complex bill review and claims adjudication, internally and externally, including but not limited to: quality repricing, bill processing timeliness, vendor QA performance, and compliance with reporting, regulatory, state, federal, jurisdictional & legal requirements. This position manages internal quality responsibilities, as well as the management of external QA vendors and/or quality reporting from Complex Bill Review ancillary partners.</p> <p>Key responsibilities:</p> <ul> <li>Conduct & manage quality audits during and after the bill review/claim adjudication process to ensure accuracy </li><li>Work with teams through ongoing feedback, reporting, education, & collaboration to improve quality & accuracy of bill review processes </li><li>Build and manage relationships with outside vendors who help with quality reviews </li><li>Make sure our team meets accuracy and timing standards and help set those standards </li><li>Identify potential system issues that arise within the audit process that affect how bills are processed & collaborate with systems admin </li><li>Keep track of audit results and spot patterns or common mistakes </li><li>Compare bill review results to budgets and pricing estimates to ensure financial accuracy & provide ongoing communication/notification to teams when variance occurs </li><li>Work with other teams to find ways to improve quality, including handling appeals, complaints, and questions </li><li>Make sure contracts are applied correctly during bill reviews </li><li>Train and support staff with updated materials and regular feedback </li><li>Help create and update internal policies and procedures to stay compliant </li><li>Give feedback to managers about staff performance and training needs </li><li>Lead or support projects to improve performance and quality </li><li>Join meetings and committees to help plan and solve problems </li><li>Support long-term planning and help identify future needs </li><li>Act as the main contact between our company and vendors for quality-related matters </li></ul> <p>Supervisor responsibilities:</p> <ul> <li>Mentor, train, and supervise team members directly and indirectly, review their work and provide effective constructive feedback. </li><li>Ensure all team members understand, are trained in, and comply with Paradigm's security requirements and policies. </li><li>Ensure all team members have the minimum level of IT system access required to effectively complete their Paradigm responsibilities. </li></ul> <p>Qualifications:</p> <ul> <li> <p>Education:</p> </li><li> <p></p> </li><li>Bachelor's degree, preferably in Business or Accounting or suitable experience. <p></p> </li><li> <p>AA Degree or equivalent college level course work; successful completion of continuing education in insurance, medical terminology/coding, accounting and workers compensation certification.</p> </li><li> <p>Experience:</p> </li><li> <p>Minimum of 3-5 years of hands-on medical bill processing, analysis, and audit oversight</p> </li><li> <p>Minimum of 3-5 years of audit experience</p> </li><li> <p>Vendor management and performance</p> </li><li> <p>Bill review software, system functionality, and training</p> </li><li> <p>Management and execution of audits of medical bill review, provider interactions, and supporting functions, preferably within both Worker's Comp and Group Health space</p> </li><li> <p>Advanced level reporting and analysis experience</p> </li><li> <p>Development and implementation of workflows, policies, and procedures, and considerable knowledge of issues and concepts in healthcare, workers compensation, and payor/billing management</p> </li><li> <p>Certified Medical Coder certification preferred. Must have advanced understanding and expertise in medical terminology and coding, as well as state workers compensation fee regulations (including ICD-9, CPT, UCR, DRG, CRVS, RBRVS, and HIPAA, State Fee Schedules, and the like)</p> </li><li> <p>Excellent organizational skills.</p> </li><li> <p>Language Skills - Excellent oral communication skills and phone presence. Ability to read and comprehend instructions, documents, etc. at an advanced level. Ability to write advanced correspondence, reports, proposals, etc. Ability to effectively present information in one-on-one and group situations to external organizations and employees of the organization.</p> </li><li> <p>Reasoning Ability - Advanced ability to define problems, collect data, establish facts, and draw valid conclusions. Strong ability to interpret a variety of instructions and deal with abstract and concrete variables.</p> </li></ul>