Medical Fee Examiner

Agency Dept of Insurance Division Industrial Commission Job Classification Title Medical Fee Examiner (NS) Position Number 60080762 Grade MH09 About Us The mission of the North Carolina Department of Insurance is to promote a stable insurance market through unbiased regulation and to protect the lives and property of every citizen in all 100 counties while fostering superior, user-friendly service, courtesy, and respect. Our agency licenses insurance agents, adjusters, bail bondsmen and more, along with investigating fraud matters involving insurance consumers and any entity or individual regulated by the Department. In an ever-changing environment, it is the vision of the Department of Insurance to maintain the stabilization of the insurance industry in order to provide more products, competitive prices and consumer protection. Description of Work Mission of the Industrial Commission The North Carolina Industrial Commission is vested as a court of exclusive and original jurisdiction by the General Assembly to adjudicate and administer the North Carolina Workers' Compensation Act. The Industrial Commission processes over 65,000 workers' compensation injury reports and claims filed annually under the Act. This responsibility includes overseeing and providing for the trial of contested cases as well as administering non-contested cases. Workers who are injured by accident on the job or who contract an occupational disease receive disability and medical benefits as ordered by the Industrial Commission. The Industrial Commission is also a court of original jurisdiction for litigating tort claims against the State under the North Carolina State Tort Claims Act. Additionally, the General Assembly has mandated the Industrial Commission to provide an adjudicated process for Childhood Vaccine-Related Injury claims and Compensation to Persons Erroneously Convicted of Felonies. It acts as a court of exclusive and final jurisdiction for death claims made by families of law enforcement officers, fire fighters, rescue squad workers and civil air patrol members arising under the Public Safety Employees' Death Benefits Act. Each of these adjudicatory systems requires administration of contested and uncontested claims, review of agreements, and supervision of payment of benefits. *This is a re-post and previous applicants are still under consideration Description of Work Medical Fee Examiner – 60080762 Salary Recruitment Range $45,651 - $47,000 Salary Grade: MH09 This position currently qualifies for a hybrid telework option with routine office and remote workdays. The posting will close at 11:59 p.m. the night before the closing date. Primary Purpose of the Organizational Unit The Medical Fees Section of the North Carolina Industrial Commission is responsible for reviewing and processing bills for medical services provided in a workers’ compensation claim when a party needs assistance applying the Commission’s Medical Fee Schedule. The Medical Fees Section also answers various medical bill and fee inquiries and is responsible for updating and maintaining the Industrial Commission’s Medical Fee Schedule. The Medical Fee Examiner also administers the informal phase of the Medical Provider Fee Dispute procedure to assist providers and parties with resolving medical fee disputes without litigation. Primary Purpose of the Position This position is responsible for the following: • Assist parties with the application of the Commission’s Medical Fee Schedule to medical bills in workers’ compensation claims by repricing the bill upon request or advising parties via telephone or email. In some cases, this will include reviewing the draft repricing prepared by a processing assistant; •Update and maintain the Medical Fee Schedule annually and as needed in conjunction with the Executive Secretary and the Commission’s Medical Fee Schedule vendor; • Issue letters to parties as needed regarding a variety of medical bill-related issues; • Advise on medical bill processing or coding issues and other questions from the public via telephone and email; • Administer the procedures of the informal phase of the Health Care Provider Fee Dispute Procedure (Rule 11 NCAC 23A .0614), including processing fee dispute requests, repricing related bills, contacting the parties for more information, requesting a response from the payor, conducting telephone conferences to help resolve the disputes, and creating a summary of the efforts to resolve the dispute if needed for the health care provider to request to intervene in the claim; • Maintain statistics on all work of the unit; and • Assist with other duties within the Medical Fees Section and Executive Secretary’s Office as needed. Knowledge Skills and Abilities/Management Preferences • Experience with Medicare reimbursement methodologies. • Demonstrated expertise in medical terminology, clinical and surgical procedures, and medical coding, applying this knowledge to accurately calculate reimbursement according to Medicare and other fee schedules. • Demonstrated ability to input data and draft business correspondence with accuracy and attention to detail, including modifying correspondence or report templates where necessary. • Demonstrated experience reviewing and processing information to determine conclusions, actions, or compliance with applicable laws, rules, or regulations. • Demonstrated experience independently responding to inquiries and coordinating a variety of resources in acquiring and disseminating information. • Demonstrated experience managing a large number of pending items and assisting in their timely completion. Minimum Education and Experience Some state job postings say you can qualify by an “equivalent combination of education and experience.” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See the E