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Reconsideration Specialist- Certified Professional Coder - Smithfield, United States - Neighborhood Health Plan of RI
Description
Job Details
Job Location Smithfield, RI - Smithfield, RI Position Type Full Time Travel Percentage Occasional Job Shift Daytime Job Category Some ExperienceDescription
Position Overview -(In office)
This position is responsible to review written inquiries related to claims edit determinations that decrease claim reimbursement. This position also reviews inquiries related to denied claims for separate reimbursement. The role reviews medical documentation submitted by the provider and makes a determination to pay or deny the services. The Claims Reconsideration Representative relies on the medical notes, benefits, payment policies, clinical medical policies, NCCI edits, coding manuals (CPT, HCPC, ICD-10) to make their determination. At times, they work with the Medical Director when medical necessity needs to be determined. When separate reimbursement is appropriate, the Reconsideration Representative will make the necessary adjustment. If the request is denied, they compose an adverse determination response to the provider.
Duties and Responsibilities:
Responsible to review and resolve provider inquiries related to claim denials and/or bundling edits.
Responsible for the review of medical notes against the adjudication of services using plan benefits, contractual reimbursement terms and industry standard coding and Neighborhood policies to determine appropriate resolution
Communicates 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
Responsible for identification and review of repetitive and/or inaccurate billing practices on a claim submission and/or content level.
Works professionally and responsibly with the Medical Director on issues of medical necessity
Works in collaboration with Provider Relations to provide claim examples for appropriate provider education
Responsible for reporting of potentially fraudulent or abusive billing patterns to the Special Investigation Unit
Must maintain coding certification(s) and remain current in coding and code edit knowledge
Recommends and develops work process improvements
Maintain cumulative reports with prior determinations to use as a repository
Maintain repository of periodicals, website links and tools used in making determinations
Collaborates with other departments on escalated issues to ensure timely resolution
Trend reconsideration results and make recommendations based on identified trends
Other duties/special projects as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Core Company-Wide Competencies:
Communicate Effectively
Respect Others & Value Diversity
Analyze Issues & Solve Problems
Drive for Customer Success
Manage Performance, Productivity & Results
Develop Flexibility & Achieve Change
Job Specific Competencies:
Collaborate & Foster Teamwork
Attend to Detail & Improve Quality
Exercise Sound Judgement & Decision Making
FDR Oversight: N/A
Travel Expectations:
N/A
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Qualifications
Qualifications
Required:
Associates degree or equivalent, relevant work experience in lieu of a degree
Three (3) or more years of direct application of coding, billing and reimbursement mechanisms
Three (3) or more years or 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
Intermediate ability working with Microsoft (Word, Excel) and PDF documents
Intermediate ability to work with Outlook or comparable email exchange program
Must be able to exercise excellent judgment and be effective working autonomously and as part of a team
Problem solver with strong attention to detail
Strong written communications skills
Extensive knowledge of all Neighborhood products and services, including all key operations and their functions and a familiarity with Medical Management and any other internal department and external vendors.(internal candidate)
Preferred:
Bachelor's degree
Prior experience within a claims operations area in a Health Care environment
Working knowledge of Fraud and Abuse Policies and Practices