Paradigm is seeking a full-time, benefitted Bill Review Specialist Lead for a hybrid position in our Tampa, FL, office. The Lead Specialist provides senior-level support for provider bills (claims) and appeals research and issue resolution. This role serves as a subject matter expert health care bill payment operations, leading the most complex and high-priority projects. Responsibilities include advanced root-cause analysis, regulatory and contract interpretation, project management, and strategic coordination across multiple departments to resolve systemic provider bills (claims), appeals, and billing issues. The Lead Specialist delivers thought leadership, develops remediation strategies, and ensures timely, accurate project execution while driving continuous improvements in claims performance and compliance. Additionally, the Lead Specialist acts as a key liaison between departments to communicate findings and resolution plans effectively.

DUTIES AND RESPONSIBILITIES:

• Receive, research, coordinate, and resolve incoming bills, appeals, or client inquiries, payment questions, and issues with internal team members, providers, or clients, as appropriate.
• Assist in reducing rework by identifying and remediating billing, appeals, and client processing issues.
• Use advanced analytical skills to conduct research and analysis for issues, requests, and inquiries on high priority claims/appeals projects.
• Evaluate processed provider payments data using standard principles and applicable state-specific policies or agreements (e.g., Single Case Agreements) to identify reimbursement or billing processing errors.
• Customize existing reports or available data to meet the needs of claims projects.
• Act as a senior provider reimbursement subject matter expert, advising on complex billing issues and ensuring compliance with regulatory and contractual requirements.
• Lead and manage major provider payments research projects of considerable complexity, initiated through provider or client inquiries or internal requests.
• Conduct advanced root-cause analysis to identify and resolve systemic bill processing errors, collaborating with multiple departments to define and implement long-term solutions.
• Interpret regulatory and contractual requirements to ensure compliance with provider payments (claims) or appeals adjudication and remediation processes.
• Develop, track, and/or monitor remediation plans, ensuring provider reimbursements (claims)/appeals reprocessing projects or inquiries are completed accurately and on time.
• Conduct periodic audits of provider payments and appeals processed by the team to ensure accuracy, compliance, and proper reimbursement, while maintaining a collaborative approach.
• Proactively identify and recommend updates to policies, SOPs, and job aids to improve claims quality and efficiency.
• Collaborate with internal stakeholders and leadership to define provider reimbursement and appeals requirements and ensure alignment with organizational goals.
• Assist in processing appeals and reconsiderations.

QUALIFICATION:

• Education – High School Diploma or equivalent required. Bachelor’s Degree or equivalent combination of education and experience: Preferred. Any combination of education, certification (CPC, CRC, etc.) experience and/or knowledge that demonstrate the ability to perform the functions of the position will be accepted.
• Experience - 5+ years in worker’s comp and/or in medical claims processing, research, or a related field (Managed Care Organization – Medicaid, Medicare, Commercial). Project management.
• Intermediate computer experience using Microsoft Word, Excel & Outlook required
• Excellent organizational skills.
• Knowledge of Worker’s Comp; Healthcare billing; ICD-9 or ICD-10; CPT; RVS; U&C; Fee Schedule; HCPCS & other coding schemes preferred.
• Language Skills - Excellent oral communication skills and phone presence. Ability to effectively tailor complex information for diverse audiences, including providers and executive leadership
• Reasoning Ability – Proven ability to manage multiple projects, prioritize tasks, and meet tight deadlines in a fast-paced environment.