Claims Reviewer
Neighborhood Health Plan (NHP) - Boston, MA

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The Claim Reviewer is responsible for the adjudication of claims adhering to NHP current administrative policies and procedures, clinical guidelines, unbundling software and other system edits. The reviewer will adjudicate the claims by reviewing hospital and/or physician contracts, fee schedules, and current billing guidelines. This requires an in-depth review of authorizations including non-clinical notes and Letters of agreement. In addition, this position also requires problem resolution skills and judgment skills to determine the appropriate staff to assist with the resolution, depending on the issue (i.e. contracting, configuration, IT, Supervisor).

Primary Responsibilities:
  • Logging all received correspondence into QNXT call tracking module.
    Manually enters claims into QNXT as needed.
  • Independently processes all types of routine claims with minimal assistance, pays, denys, or pends as appropriate in a timely and accurate manner
  • Meets quantity and quality claims processing standards.
  • Maintains current knowledge of assigned plan(s) and effectively applies this knowledge in the processing of claims and in providing customer service.
  • Review and interpret information from various sources and databases such as Med Solutions High Tech Radiology, Claim Check, and other vendors and software.
  • Assists other staff with questions pertaining to the processing of claims; directs questions and problems to the appropriate person for resolution.
  • Process troubleshooter reports as assigned.
  • Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner.
  • Other duties as assigned.

Preferred Qualifications:

High School Diploma or equivalent experience

2-3 years of previous experience in the health insurance industry in functions such as hospital or physician biller, call center experience, previous claims processing or similar industry experience

Knowledge of ICD-9, HCPCS, CPT-4, and Revenue Codes. Knowledge of medical terminology. Knowledge of claim forms (professional and facility), knowledge of paper vs. electronic filing and medical billing guidelines

Previous experience in manual pricing

Previous experience in processing pended claims (5 edits or more)

Completion of coding classes from certified medical billing school. Professional Coder Certificate is highly desirable

NHP offers competitive salaries and an excellent flexible benefits package that includes medical, dental and vision insurance, generous earned time, commuter benefit, and a 401(k) employer contributed retirement program.

NHP’s mission targets a diverse population and our employees are just as diverse. As an equal opportunity employer, NHP recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.