Workers' Compensation Appeal Specialist

Reliant Health Partners is an innovative medical claims repricing service provider, helping employers achieve maximum health plan savings with minimum noise. We tailor our services to each client’s needs, providing everything from individual specialty claims repricing, to full plan replacement as a high-performance, open-access network alternative.

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.
• Individual compensation will be commensurate with the candidate's experience and qualifications. Certain roles may be eligible for additional compensation, including bonuses, and merit increases. Additionally, certain roles have the opportunity to receive sales commissions that are based on the terms of the sales commission plan applicable to the role.