Bill Review Specialist

ABOUT US:

Ethos Risk Services is a leading insurance claims investigation and medical management company committed to providing better data that translates into better decision-making for our clients. We are at the forefront of innovation in our space, and our success is driven by a dynamic team passionate about delivering exceptional services to our customers.

JOB SUMMARY:

Our dynamic Bill Review team is seeking a full-time Bill Review Specialist (REMOTE) to review, audit, and process workers' compensation medical bills while ensuring compliance with state fee schedules, regulatory requirements, and client-specific guidelines. The ideal candidate is analytical, organized, and committed to delivering accurate, high-quality work in a fast-paced environment.

KEY RESPONSIBILITIES:

• Analyze Medical Bills – Review and adjudicate hospital, ambulatory surgery center (ASC), durable medical equipment (DME), pharmacy, transportation, home health, and other specialty medical bills for reimbursement accuracy and compliance.
• Research Provider Appeals – Investigate provider appeals, reconsiderations, and billing disputes by interpreting applicable fee schedules, reimbursement methodologies, regulations, and client guidelines.
• Prepare Reimbursement Determinations – Draft clear, professional written correspondence explaining payment decisions and reimbursement methodologies to providers.
• Communicate with Providers – Respond to provider inquiries via phone and written correspondence regarding reimbursement decisions, payment methodologies, and billing questions.
• Support Cross-Functional Teams – Partner with the Account Management team and other internal stakeholders to resolve billing issues, answer client questions, and support operational objectives.

QUALIFICATIONS:

Education: High school diploma or equivalent (required). Associate's degree or higher is preferred.

Experience:

• Minimum of 3 to 5 years of workers' compensation bill review experience, reviewing and adjudicating medical bills using state fee schedules, PPO contracts, reimbursement methodologies, client guidelines, and applicable workers' compensation regulations. (required).
• Knowledge of CPT, ICD-10, HCPCS (required).
• Experience using Conduent Strataware software, CompIQ software (preferred).
• Experience in billing accuracy, reimbursement eligibility, code relationships, bundled services, modifier usage, and reimbursement calculations while applying regulatory and client-specific guidelines (required).
• Experience applying multi-state workers' compensation fee schedules, reimbursement methodologies, payment policies, and jurisdiction-specific regulations (preferred).
• Experience researching complex reimbursement issues, fee schedules, and regulatory guidance to support accurate and defensible payment determinations (preferred).
• Experience managing provider appeals, reconsiderations, and billing disputes, including communicating reimbursement methodologies and payment decisions (preferred).
• Experience reviewing complex medical bills, including hospital, ASC, DME, transportation, home health, dental, and other specialty bill types involving advanced reimbursement analysis (preferred).

REMOTE WORK & BENEFITS:

This is a 100% remote U.S.-based role, offering the flexibility to work from home while remaining closely connected to a collaborative leadership team.

Benefits include: Paid Time Off & Sick Time | Medical, Dental, and Vision Insurance | Life Insurance | Short-Term, Long-Term & Disability Insurance | 401(k) Matching | Employee Referral Bonus Program & more!

Candidates must be authorized to work in the United States and must not require current or future employment sponsorship.

At Ethos, you'll have the opportunity to make a meaningful impact, shape the future of our engineering organization, and help build the systems and processes that support our next stage of growth. To learn more about Ethos, visit our website: About Us - Ethos Risk

Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic.