Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm’s business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs. We’re to be recognized—again! For the fourth year in a row, we’ve been certified by and for the third consecutive year, we’ve earned a spot on Fortune's Best Workplaces in Health Care™ list. These honors reflect our unwavering commitment to fostering a positive, inclusive, and employee-centric culture where people thrive. Watch this short video for a brief introduction to Paradigm. This position holds accountability for accurate and timely processing and payment of considerably difficult bills to include pre-coding and adjudication of medical bills. - Examines, enters and adjudicates bills for all provider types, product lines, bill types and lines of business. - Meets or exceeds department contractual and/or industry standards for accuracy and turnaround time. - Maintains an understanding of all variations of Workers’ Compensation state rules and regulations. - Maintains comprehensive knowledge of all available re-pricing opportunities (e.g. PPOs, direct contracts, etc.), ensures application as part of the adjudication process. - Monitors itemized billings for excessive charges, duplications, and appropriate medical bills coding. - Reviews bills for required information, pends bills if appropriate and maintains follow-up / alert systems, updates files and releases pends when indicated. - Tracks and reports production, downtime, issues and trends. - Serves as back-up for all Claims examination, processing positions to handle inventory fluctuations or staff shortages. - Reviews/processes appeals and initiates refund requests, assists in the recoupment process. - Assists with audits/review of bills. - Assists in the preparation of bills research reports. - Adjusts benefit calculation for under/overpayments. - Provides customer service to render efficient customer satisfaction, including timely response and resolution to customer issues, complaints, questions and requests. - May be responsible for special projects. - Education - AA Degree or equivalent college course work; successful completion of continuing education in insurance, medical terminology/coding, and/or accounting. - Experience - 5 years of claims examining or bill review experience. Intermediate computer experience using an MS Word, MS Excel & Outlook required. Typing speed of 60 WPM on data entry. Excellent organizational skills. Knowledge of ICD-10; CPT; Revenue Code; RVS; U&C; Fee Schedule; RBRVS; DRG; HCPCS & other coding schemes. - Language Skills - Excellent oral communication skills and phone presence. Ability to effectively present information to providers as well as to employees of the organization. - Reasoning Ability - Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret a variety of instructions and deal with abstract and concrete variables. - Health and wellness– We want our people to be and stay healthy, so we offer PPO, HDHP, and HMO health insurance options with Cigna and Kaiser (CA employees only). - Financial incentives – Paradigm’s financial benefits help prepare you for the future: competitive salaries, 401(k) matching contributions, employer-paid life and disability insurance, flexible spending and commuter accounts, and employer-matched HSA contributions. - Vacation - We believe strongly that work-life balance is good for you and for our company. Our paid time off and personal holiday programs give you the flexibility you need to live your life to the fullest. - Volunteer time– We want our employees to engage with and give back to their communities in meaningful ways. Full and part-time employees receive one paid day per calendar year. - Learning and development: One of Paradigm’s core values is expertise, so we encourage our employees to continually learn and grow. We support this in a variety of ways, including our new Learning Excellence at Paradigm (LEAP) program. Paradigm believes that fostering a diverse and inclusive workplace is central to our mission of helping more people and transforming lives. We’re striving to build a culture that better reflects the society we live in and empowers our team to deliver the highest levels of compassion and care to those we serve. For us, achieving this goal requires a workforce that respectfully embraces differences and commits to positive change, creating an environment where everyone is able to bring their whole self to work. Paradigm complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact Leave Management at leave.management@paradigmcorp.com. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.