Claim Reconsideration Specialist
Neighborhood Health Plan of Rhode Island 4 reviews - Providence, RI

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The role of the Claim Reconsideration Specialist is to provide consistent, single point of contact service to our provider network concerning issues and inquiries related to claims edit determinations and requests for separate reimbursement. The representative is also responsible for triage of issues which require escalation.



- High school graduate or equivalent

- Demonstrated knowledge of industry standard coding ( including procedural and diagnosis code sets), reimbursement methodologies, and medical terminology

- A minimum of 3 - 5 years of direct application of coding, billing and reimbursement mechanisms via claims processing and/or medical billing experience

- Prior experience with claims editing software

- Demonstrated working knowledge of medical record documentation requirements and interpretation as it relates to claim reimbursement

- Experience communicating with provider networks both verbally and in print

- Demonstrated experience in data collection, presentation and action plans

- Demonstrated ability to effectively prioritize and execute tasks and special projects

- Demonstrated ability working with Microsoft Word and Excel

- Strong verbal written communications skills

- Ability to work both independently and as a team member


- American Academy of Professional Coder’s Certification ( s)

- Some College or Bachelor’s Degree

- Related Professional Training and/or Certifications

- Prior experience within a claims operations area in a Health Care environment

- Working knowledge of Fraud and Abuse Policies and Practices

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:

- Responsible for the review and adjudication of services flagged by claims editing software within the claims transactional system, according to plan benefits, contractual reimbursement terms and industry standards

- Responsible for review and resolution of provider correspondence related to claim denials generated by claims editing software

- Responsible for review and resolution of customer service issues related to claims reimbursement edits

- Responsible for analysis and recommendations to increase the automation of claims edits

- Responsible for identification and review of repetitive and/or inaccurate billing practices on a claim submission and/or content level. This includes data mining rejected claim submissions, adjudicated claims as well as a review of all claims that have flagged for a data submission warning errors

- Responsible for determining if correct billing/coding requirements have been met including but not limited to; service to diagnosis compatibility, patient and provider demographic compatibility, revenue to service code compatibility, claim form field data validity

- Responsible for outreach to providers to promote provider education via written and verbal correspondence

- Responsible for recommendations for areas of provider claim submission and/or billing and reimbursement education

- Responsible for triage of potentially fraudulent or abusive billing patterns to the Claims Auditing Unit.

- Responsible for triage of configuration issues

- Develop and maintain cumulative reports and spreadsheet

- Retroactive adjustment projects, as assigned

- Special projects as assigned

Neighborhood is an EOE M/F/D/V and an E-Verify Employer.

About this company
4 reviews
The overall health of the people of Rhode Island is overseen by the Rhode Island Department of Health, which is overseen by a...