Clinical Rater Jobs in Florida (NOW HIRING)

We are seeking a full-time, remote Clinical Budgeting Specialist. This position is responsible for the accuracy of risk-based contract budgets and subsequent forecasts. This will be accomplished by working in collaboration with multiple teams including Clinical Operations, Provider Contracting, Bill Review, Analytics, and senior management.

Demonstrates a customer-first mindset through a commitment to delivering the best possible outcomes for our customers, including injured workers, payors, clients, providers, stakeholders, and internal teams. By fully leveraging Paradigm’s solutions, delivering consistently highquality service, and collaborating effectively with internal and external partners, we create an exceptional customer experience.

RESPONSIBILITIES:

• Serve as a resource for Paradigm Clinical Management staff as it relates to financial liability for all provider services and other Contract-related costs.
• Partner with Director Clinical Solutions to manage the development of all new Contract budgets, including participation in clinical conferences.
• Research and document patient driven costs and provider rates that drive budget development and management.  Utilize web driven and other electronic resources to identify potential costs, including use of CPT codes in the company’s electronic claims adjudication system.
• Complete all Provider Rate Negotiation (PRN) requests to include accurate documentation of known or estimated financial liability in the system.
• Develop relationships with providers, including preferred provider organizations (PPOs), hospitals and specialty providers, ancillary services providers, and physicians.
• Maintain current knowledge of regulatory, industry and contractual factors to ensure the accurate estimation of Paradigm’s liability on each Contract.
• Collaborate with other internal departments (Contracting, Bill Review, Accounting) to address and resolve specific patient / provider issues.
• Analyze contract budget to actual (frequency based on contract parameters) to evaluate the clinical requirements and clinical management requirements for both acute and chronic cases.  Develop action plans in collaboration with the PMT to manage the budget expenditures in order to keep the Contract on track financially.
• Collaborate with the clinical team including the Director of Clinical Solutions to determine the current and future medical/financial course and its impact to the financial forecast.
• Complete detailed review of clinical progress reports for key significant financial events and/or clinical confinements as well as a comprehensive review of paid claims.  Update each forecast with findings/changes to include; update and confirmation of known/future service dates and expense using reference data and/or direct contract with the providers, true-up of forecast for completed services to paid claims, adjustment for future services based on changes in the clinical course of treatment.
• Work with the contracting department to request negotiations on interim services and escalate issues related to outstanding confinement bills variations in paid claims estimates.
• Work with the Risk Analytics Team to determine trends and identify improvements that can be made to enhance the accuracy and ease of budget development and/or forecasting.
• Participate as required in Paradigm internal staff development programs.
• Utilizes AI tools to support day-to-day tasks, improve efficiency, and enhance output quality. Adopts new technologies as trained and apply them in alignment with established processes and guidelines.
• Demonstrates a customer-first mindset by developing a broad and deep (where appropriate) understanding of Paradigm organization, products, operations, and customers. Prioritizes collaboration to meet customer needs and expectations and takes personal accountability for service quality.

QUALIFICATIONS:

• Education - Bachelor’s Degree in health care administration, business, finance or a related field from an accredited college or university or equivalent experience and education which demonstrates the ability to perform the functions of the position.
• Experience – A minimum or combination of five years of experience with demonstrated success in health care or related field.
• Medical coding certification preferred.
• Medical billing in workers compensation industry preferred
• Prior experience reviewing medical documentation and assigning CPT codes to determine workers’ compensation fee schedule reimbursement.
• Must maintain current understanding of state regulations and their impact on medical care and reimbursement in the workers’ compensation care market.
• Strong medical background to include comprehensive understanding of medical terminology and health care principles and practices.
• Demonstrated ability to multi-task in a fast-paced work environment, assess importance of activities, and adjust priorities when appropriate.
• Experience with various computer applications including Microsoft Office, Outlook, Word and Excel.
• Language Skills - Excellent oral and written communication skills; able to make presentations to audiences of varying levels, size, nature and backgrounds.
• Reasoning Ability - Demonstrated ability to analyze difficult situations, problems and data and develop feasible and effective solutions.  Demonstrated ability to implement and monitor project responsibilities. 
• Any combination of education, experience and knowledge that demonstrate the ability to perform the functions of the position will be accepted.