State Reporting Specialist

Prime Health Services (PHS) is a national medical cost containment company with a noteworthy PPO Network used by insurance carriers, TPA’s, self-insureds, and governmental entities. Our tech-focused nature allows clients to take advantage of the flexibility of customization while not compromising on bill processing speed. Since 2001, we have specialized in medical provider network development and offer clients a tailored approach to medical cost containment: quality health care at discounted rates.

The State Reporting Specialist is an essential part of Prime Health Services’ (PHS) Compliance team. This position reports to the Senior Compliance Manager and works collaboratively with the Fee Schedule and IT teams to ensure that state EDI reporting requirements are met. It requires a high level of attention to detail and knowledge of Workers’ Compensation Medical EDI reporting. The State Reporting Specialist reviews the state requirements for EDI states and maps data from PHS’ proprietary bill review platform to the EDI submission to the state, while following the state’s submission requirements. This position ensures that PHS provides up-to-date and accurate reporting to all bill review clients. Errors are sent back to the client by the state. The State Reporting Specialist either updates or advises the client how to correct those bills to properly submit them to the state.

Essential Job Functions

• Manages relationships with multiple state jurisdictions and creates accurate state reporting.
• Ensures all data elements from PHS’s proprietary bill review system are captured and mapped as required, per state regulations.
• Creates, updates, and maintains work process with the Compliance Fee Schedule team to ensure all reporting requirements are met.
• Communicates with clients regarding state reporting error files and/or questions regarding reporting of medical bills.
• Ensures that Prime State Reporting adheres to requirements specific to each state to ensure we do not incur penalties associated with being out of compliance.
• Performs other related duties as assigned.

• High school diploma or GED, plus 5 years of relevant work experience is required
• Associate’s or Bachelor’s Degree in Business or related field of study from an accredited college or university, plus 2 years of relevant work experience, i.e. medical billing, medical office, etc., is preferred
• Excellent organizational skills, detail-oriented and ability to coordinate and complete multiple tasks in a self-paced environment
• Excellent understanding of EDI data elements and requirements
• Knowledge of multiple state jurisdictional regulations and rules is preferred
• Working knowledge of workers’ compensation fee schedules, rules, and usual & customary guidelines is required
• Knowledge of medical terminology, anatomy and surgical terms is preferred