Claims Reconsideration Specialist - JHP

Claims Reconsideration Specialist

Working under general supervision, the Claims Reconsideration Specialist is responsible for the resolution of provider claim reconsideration requests, member billing complaints and related issues involving claim adjustment processing via correspondence, portals and projects.

Essential Functions:

• Able to work in a constant state of alertness and safe manner
• Handle and resolve claim inquiries, complaints and appeals received from providers.
• Resolve all assigned claim reconsideration requests through MACESS, including completing any correspondence directed to external or internal entities.
• Process routine claim adjustments resulting from external inquiries, other internal department referrals.
• Claim quality review efforts in a timely manner according to established guidelines.
• Investigate and facilitate timely resolution of pended claims using MACESS service forms within 72 hours of receipt.
• Investigate and facilitate timely resolution of provider portal claim reconsiderations.
• For reconsideration requests submitted on excel spreadsheets, document outcome of appeal in designated fields by timelines assigned by Team Leader or Supervisor.
• Analyze claims adjudicated in error, making recommendation to Supervisor or Team Leader for process improvements.
• Meet production and quality expectations for the department. Properly document all claim review activity through application of hold codes.
• Provide accurate and complete information in response to providers' claim inquires.
• Follow established procedures and guidelines for claims processing and high dollar review.
• Assist the unit in meeting and maintaining performance standards.

Required Education and Experience:

Education:

• High school diploma or equivalency-Required
• Three years of Claims processing experience; medical billing; or medical coding experience-Preferred

Skills/Abilities:

• Excellent communication skills- both oral and written-Preferred.
• Knowledge of CPT-4, HCPCS and ICD-10 coding schemes-Preferred.
• General understanding of the principles of Managed Care-Preferred

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.