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. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

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.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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