Bill Review Analyst Lead - Complex Claims

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, remote Medical Bill Analyst Lead for our Complex Claims department. The Medical Bill Analyst Lead performs advanced medical bill review and adjudication while providing day-to-day guidance, technical support, and subject-matter expertise to the Medical Bill Processor and Medical Bill Analyst teams. This role supports management in maintaining the highest standards of accuracy, compliance, productivity, and customer service, and assists with training, quality initiatives, audits, and complex or exception bill processing. DUTIES AND RESPONSIBILITIES:

• Examine, review, and adjudicate medical bills across all provider types, product lines, and lines of business, including complex and exception bill types.
• Apply appropriate repricing methodologies and ensure billing accuracy by monitoring for excessive charges, duplicate billing, and coding errors.
• Serve as a liaison between analysts, processors, and leadership, escalating trends, risks, system issues, and training needs.
• Participate in audits, quality reviews, and special projects; review and resolve billing appeals and initiate recovery or refund actions as needed.
• Provide backup bill review and claims examination support during workload fluctuations and maintain reliable attendance during scheduled work hours.
• Provide coaching, mentoring, and technical guidance on complex bill review, adjudication decisions, and exception handling; support onboarding and ongoing education.

QUALIFICATION REQUIREMENTS:

• Education: High School Diploma or equivalent required. Bachelor’s Degree or equivalent combination of education and experience preferred. Any combination of higher education, certification (CPC, CRC, etc.), experience and/or knowledge that demonstrate the ability to perform the functions of the position will be accepted.
• Experience in worker’s comp and/or in medical claims processing, research, or a related field (Managed Care Organization – Medicaid, Medicare, Commercial). Project management required.
• Intermediate computer experience using Microsoft Word, Excel and Outlook required.
• Excellent organizational skills.
• Knowledge of worker’s comp; healthcare billing; ICD-9 and ICD-10; CPT; RVS; U&C; fee schedule; HCPCS and other coding schemes preferred.
• Language Skills: Excellent oral communication skills and phone presence. Ability to effectively tailor complex information for diverse audiences, including providers and executive leadership.
• Reasoning Ability: Proven ability to manage multiple projects, prioritize tasks, and meet tight deadlines in a fast-paced environment.

Paradigm Benefits:

• 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 [email protected]. 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. As a contractor with the State of Wisconsin, Paradigm complies with Wisconsin Contract Compliance Law (§16.765). Poster link: Contract Compliance Law Poster Apply tot his job Apply To this Job