Medical Claims Reconsideration Specialist

3 weeks ago


Smithfield, Utah, United States Neighborhood Health Plan of RI Full time
Claims Reconsideration Representative Job Description

Neighborhood Health Plan of Rhode Island is seeking a highly skilled Claims Reconsideration Representative to join their team. As a Claims Reconsideration Representative, you will be responsible for reviewing written inquiries related to claims edit determinations that decrease claim reimbursement. You will also review inquiries related to denied claims for separate reimbursement, utilizing medical documentation submitted by the provider to make a determination to pay or deny the services.

The ideal candidate will have a strong understanding of medical record documentation requirements and interpretation as it relates to claim reimbursement. They will also have experience with claims editing software and a working knowledge of contract implementation and contract language. The successful candidate will be able to exercise excellent judgment and be effective working autonomously and as part of a team.

Key Responsibilities:
  • Review and resolve provider inquiries related to claim denials and/or bundling edits
  • Review medical notes against the adjudication of services using plan benefits, contractual reimbursement terms, and industry standard coding and Neighborhood policies to determine appropriate resolution
  • Communicate adverse determination to provider via written correspondence
  • Perform any necessary claim adjustments for overturned determinations directly in the HealthRules system
  • Request appropriate adjustment via AWD to the Claims BPO
  • Identify and review repetitive and/or inaccurate billing practices on a claim submission and/or content level
  • Work professionally and responsibly with the Medical Director on issues of medical necessity
  • Collaborate with Provider Relations to provide claim examples for appropriate provider education
  • Report potentially fraudulent or abusive billing patterns to the Special Investigation Unit

Requirements:

  • Associates degree or equivalent, relevant work experience in lieu of a degree
  • Three or more years of direct application of coding, billing, and reimbursement mechanisms
  • Three or more years of prior claims processing and/or medical billing experience
  • Current certification from the American Academy of Professional Coder's (AAPC) or American Health Information Management (AHIMA)
  • Prior experience with claims editing software
  • Demonstrated working knowledge of medical record documentation requirements and interpretation as it relates to claim reimbursement
  • Basic understanding of contract implementation and working knowledge of contract language
  • Experience with Optum encoder, similar coding software/website
  • Knowledge of HIPAA standards and CMS guidelines
  • Excellent ability to effectively prioritize and execute tasks and special projects


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