Bill Review Quality Program Lead - Military veterans preferred

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 proud to be recognized—again! For the fourth year in a row, we’ve been certified by Great Place to Work®, 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.

Paradigm is seeking a full-time, benefitted Bill Review Quality Program Lead for a hybrid position in Tampa, FL. The schedule is Monday through Friday, regular business hours, with 1-2 days in office and 3-4 days working from home.

The 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.

DUTIES AND RESPONSIBILITIES:

• Manage Quality Control functions, as well as conducts audits, ensuring that in-flight bill audits and reviews are completed for the operations teams.
• Manage Quality Assurance functions ensuring that retrospective bill audits & reviews are completed for the operations teams.
• Develop, enhance, and/or expand quality function through current state analysis, definition of goals/strategies, and execution of new processes, reporting, etc.
• Develop QA partnership strategy & plan with external QA vendors, with the support & direction of Complex Bill Review leadership.
• Manage vendor partnerships of QA-related vendors, as well as works incorporation of QA results from general Complex Bill Review partners, ensuring a wholistic & comprehensive view into quality of the Complex Bill Review department at large.
• Ensures that the internal and external performance standards for accuracy and timeliness are met, assists in the development of bill review performance standards for internal and external sources (i.e., employer group contracts); ensures performance standards are consistent with industry standards; tracks, analyzes trends and reports information.
• Supports system and platform maintenance and updates through identification of system-related bill processing errors, as needed.
• Develop, maintain, and analyze accurate records of audit results and trends. Identify and document patterns of errors made by internal and/or external complex bill review personnel.
• Conduct analysis of complex bill repricing outcomes compared to internal case/contract budgets, pricing estimates, and/or forecasts, working with underwriting, pricing, and clinical management leadership to ensure financial accuracy and support financial audit functions.
• Develop process and support ongoing coordination with various complex bill review team members and leaders as it relates to opportunities for further quality improvement. For example, ensuring reconsideration/appeal/disputes, penalty payments, provider complaints, and underwriting team questions are factored into current quality measurement.
• Ensure the proper and consistent application of Paradigm contracts to complex bills through quality audits.
• Conduct training of staff within the complex bill review group, including maintaining documentation, training materials, and employee education through quality feedback & ongoing education sessions and workshops.
• Oversees the development of internal system policies and procedures. Ensure that internal operations are in compliance and consistent with regulations, record keeping and reporting requirements.
• Collaborates with Bill Review Manager to provides feedback on staff quality performance, such as training opportunities, audit status and any significant development affecting quality bill review processing.
• Management and/or participation in the development & execution of quality-related performance improvement plans.
• Serve on regular committees and inter-departmental meetings and task forces to support the Bill Review Department in planning, analysis and troubleshooting capacities.
• Assist management with long range goals and projects. Anticipate opportunities as well as needs.
• Liaison between Paradigm and the bill review, data entry and medical record vendors, as it relates to quality functions.

SUPERVISORY RESPONSIBILITIES:

• Mentor, train, and supervise team members directly and indirectly, review their work and provide effective constructive feedback.
• Ensure all team members understand, are trained in, and comply with Paradigm’s security requirements and policies.
• Ensure all team members have the minimum level of IT system access required to effectively complete their Paradigm responsibilities.

QUALIFICATION REQUIREMENTS: To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Education:
  • Bachelor’s degree, preferably in Business or Accounting or suitable experience.
  • AA Degree or equivalent college level course work; successful completion of continuing education in insurance, medical terminology/coding, accounting and workers compensation certification.
• Experience:
  • Minimum of 3-5 years of hands-on medical bill processing, analysis, and audit oversight
  • Minimum of 3-5 years of audit experience
  • Vendor management and performance
  • Bill review software, system functionality, and training
  • Management and execution of audits of medical bill review, provider interactions, and supporting functions, preferably within both Worker's Comp and Group Health space
  • Advanced level reporting and analysis experience
  • Development and implementation of workflows, policies, and procedures, and considerable knowledge of issues and concepts in healthcare, workers compensation, and payor/billing management
• 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)
• Excellent organizational skills.
• 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.
• 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.