Workers' Compensation Appeal Specialist

As a Workers’ Compensation Appeals Specialist, you will play a critical role in resolving post-payment disputes related to Workers’ Compensation bills. This includes conducting provider outreach, negotiating disputed charges, and ensuring compliance with state-specific regulations. Your work will directly support our cost containment efforts and ensure appropriate bill reimbursement for our clients.

Primary Responsibilities

• Manage a caseload of post-payment Workers’ Compensation bills, including those related to state balance billing and usual and customary rate (UCR) disputes.
• Conduct proactive outreach to medical providers to explain payment methodologies, resolve disputes, and negotiate reductions on appealed or outlier bills.
• Communicate effectively and professionally with clients to coordinate and investigate information as it relates to the case/appeal.
• Educate providers on Workers’ Compensation billing and reimbursement policies and regulatory requirements.
• Document all provider communications thoroughly, including contact information, bill details, proposed and counter-offered payment rates, and final resolution.
• Adhere to state-specific compliance standards and confidentiality requirements, including HIPAA.
• Maintain productivity and quality standards, ensuring timely resolution of bills in accordance with state timelines.
• Follow client-specific protocols and internal Reliant procedures, including scripting and documentation guidelines.
• Stay current on Workers’ Compensation regulatory changes, fee schedules, and payment policies across multiple states.
• Works as an effective team member.
• Support special projects and perform additional duties as assigned.

Qualifications

• 2–3 years of relevant experience in Workers’ Compensation bills, medical billing, medical coding, or insurance negotiations.
• Strong understanding of Workers’ Compensation reimbursement methodologies, state regulations, and provider billing practices.
• Experience negotiating medical bill payments or adjustments with providers.
• Ability to collaborate with a variety of individuals both internally and externally.
• Familiarity with claims processing systems and provider communications.
• Excellent communication, negotiation, and organizational skills.
• Requires organizational skills, communication proficiency, discretion, ethical conduct, decision making, technical skills.