Claims Reconsideration Specialist - JHP

Job Details

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.

Job Description

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

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students.