Job Description

ABOUT US:

Ethos Risk Services is a leading provider of workers' compensation medical management, investigations, and claims solutions, dedicated to helping clients make better decisions through industry expertise, innovation, and exceptional service. As we continue to grow, we're expanding our cost containment capabilities through Definiti, a national leader in medical bill review, pharmacy benefit management, PPO network solutions, and reimbursement services. Together, we're building a comprehensive suite of solutions that helps clients reduce costs, improve efficiency, and achieve better claim outcomes.

Our dynamic Bill Review team is seeking a full-time Bill Review Specialist to review, audit, and process workers' compensation medical bills while ensuring compliance with state fee schedules, regulatory requirements, and client-specific guidelines. The ideal candidate is analytical, organized, and committed to delivering accurate, high-quality work in a fast-paced environment.

KEY RESPONSIBILITIES:

• Analyze Medical Bills – Review and adjudicate hospital, ambulatory surgery center (ASC), durable medical equipment (DME), pharmacy, transportation, home health, and other specialty medical bills for reimbursement accuracy and compliance.
• Research Provider Appeals – Investigate provider appeals, reconsiderations, and billing disputes by interpreting applicable fee schedules, reimbursement methodologies, regulations, and client guidelines.
• Prepare Reimbursement Determinations – Draft clear, professional written correspondence explaining payment decisions and reimbursement methodologies to providers.
• Communicate with Providers – Respond to provider inquiries via phone and written correspondence regarding reimbursement decisions, payment methodologies, and billing questions.
• Support Cross-Functional Teams – Partner with the Account Management team and other internal stakeholders to resolve billing issues, answer client questions, and support operational objectives.

QUALIFICATIONS:

Education: High school diploma or equivalent (required). Associate's degree or higher is preferred.

Experience:

• Minimum of 3 to 5 years of workers' compensation bill review experience, reviewing and adjudicating medical bills using state fee schedules, PPO contracts, reimbursement methodologies, client guidelines, and applicable workers' compensation regulations. (required).
• Knowledge of CPT, ICD-10, HCPCS (required).
• Experience using Conduent Strataware software (preferred).
• Experience in billing accuracy, reimbursement eligibility, code relationships, bundled services, modifier usage, and reimbursement calculations while applying regulatory and client-specific guidelines (required).
• Experience applying multi-state workers' compensation fee schedules, reimbursement methodologies, payment policies, and jurisdiction-specific regulations (preferred).
• Experience researching complex reimbursement issues, fee schedules, and regulatory guidance to support accurate and defensible payment determinations (preferred).
• Experience managing provider appeals, reconsiderations, and billing disputes, including communicating reimbursement methodologies and payment decisions (preferred).
• Experience reviewing complex medical bills, including hospital, ASC, DME, transportation, home health, dental, and other specialty bill types involving advanced reimbursement analysis (preferred).

WORKING CONDITIONS:

This position offers flexible work arrangements, including hybrid or full on-site options, based on business needs and management approval. The office is located at 26445 Rancho Parkway Street, Lake Forest, CA 92630

Flexible start times are available between 6:00 a.m. and 9:00 a.m., with eligibility for a 9/80 alternate work schedule (every other Monday or Friday off) following successful completion of training, satisfactory performance, business needs, and management approval.

Ethos Risk Services and Definiti Comp Solutions is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic.