Claims Reconsideration Coder

Location: Smithfield, RI. (On-site)

Position Overview

The Claims Reconsideration Coder (CRC) is a multidisciplinary Certified Professional Coder accredited through the American Academy of Professional Coders or Certified Coding Specialist accredited through American Health Information Management Association. This role will evaluate medical record documentation by abstracting the pertinent information that supports the services billed to allow a determination for payment or denial on claim submissions that meet the criteria for a medical note review. Relies on sound review methods applied to the content of the medical notes, benefits, payment policies, clinical medical policies, NCCI edits, CMS, coding manuals (CPT, HCPC, ICD-10), and other industry supported resources required to independently make their determination. This role attends bi-weekly meetings with the Medical Director to present claims that require a medical necessity determination. When separate reimbursement is appropriate, the CRC will make the necessary adjustment. If the request is denied, they compose an adverse determination response to the provider. The Coder uses self-directed, decision making and problem solving that directly impacts financial outcomes and results.

Duties and Responsibilities:

Responsibilities include, but are not limited to:

• Responsible for all aspects of Claim Reconsideration Requests and Contracted Provider Administrative Appeals including reviewing, resolving, adjusting, and development of written communication to providers
• Independently abstract and interpret of all medical notes required to determine if the services billed are supported for reimbursement using current industry standard coding, CMS guidelines, plan benefits, contractual reimbursement terms, and Neighborhood policies
• Communicate adverse determination to Provider via written correspondence
• Responsible for identification, review and reporting of inaccurate billing practices and trends gleaned from reconsideration determinations and coding/billing knowledge

• Work in conjunction with the Medical Director on issues of medical necessity and resolution
• Work in collaboration with Provider Relations team to provide claim examples for appropriate provider education. Collaborates to create and revise educational materials.
• Responsible for reporting of potentially fraudulent or abusive billing patterns to the Special Investigation Unit
• Maintain audit documentation and cumulative reports with prior determinations for utilization as a repository
• Continuously maintain repository of periodicals, website links and tools used in making determinations

• Perform any necessary adjustments on the claim(s) affected directly by reconsideration determinations in the HealthRules system
• Request appropriate adjustment on the claim(s) affected to the Claims BPO
• Identify process improvements and collaborates with appropriate personnel and departments as needed for implementation
• Maintain annual Continuing Education Units (CEU) required to sustain their knowledge and accreditation certificate from the AAPC or AHIMA. This includes remaining up to date on coding changes and guidelines.

• Perform other duties and/or 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
• Attention to Detail & Quality Improvement
• 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:

• Associate's degree or equivalent, relevant work experience in lieu of a degree
• Current certification from the American Academy of Professional Coder's (AAPC) Certified Professional Coder or American Health Information Management (AHIMA) Certified Coding Specialist
• Three (3) or more years of direct application of coding, billing, and reimbursement mechanisms
• Three (3) or more years of prior claims processing and/or medical billing experience
• Prior experience with claims editing software
• Prior experience with claims billing or payment systems
• Demonstrated working knowledge of medical record documentation requirements and interpretation as it relates to claim reimbursement
• Demonstrated knowledge of NCCI, CPT, HCPC, ICD-10-CM, and ICD-10-PCS coding edits
• Knowledge of established norms and guidelines in the industry
• 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 implement tasks/special projects within deadlines
• Intermediate skills working with Microsoft Office products including Outlook and PDF documents
• Superior analytical and problem-solving skills
• Extreme attention to detail, highly developed organizational skills, and ability to prioritize assignments
• Strong written communications skills
• Positive and professional attitude, with a strong emphasis on working as a team

Preferred:

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    • Bachelor's degree
    • Prior experience within a claims operations area in a Health Care environment
    • Working knowledge of Fraud, Waste and Abuse Policies and Practices