Claims Reconsideration Specialist - JHP

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
• 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

Education Required

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

Skills/Abilities

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