Job Description

Job Description

Job Description

• Seeking a Claims Reconsideration Coder for a temporary to permanent hire position with a prestigious insurance company in RI.
• This position is immediately available for the successful candidate. Experience is preferred; however, consideration will be given to newly certified applicants who have passed the certification exam and can present their certification number.

This is a full-time position working 37 1/2 hours weekly, and offers a comprehensive benefits package when/if hired permanently.

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 company 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

• 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 Health Rules system
• 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

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

The interested candidate must have strong communication skills, be organized, have the ability to prioritize tasks, have problem solving skills, have a positive attitude and enjoy working as part of a team,

Must be able to pass a background check .

For immediate consideration please submit your resume.

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