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

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