• Claims and Edit Policy Specialist

    Job Locations US-RI-Smithfield
    Req No.
    Provider Network Management
    Regular Full-Time
  • Overview

    This position is responsible for two essential functions within the Provider Network Management Department. He/she is responsible for the development, coordination and maintenance of Neighborhood’s reimbursement policies, including integration of clinical medical policies. In addition, this position is responsible for assuring Neighborhood’s editing software aligns with industry standards.


    • Act as subject matter expert for claims editing software
    • Responsible for continuous monitoring of Centers for Medicare & Medicaid Services and other applicable industry standards
    • Responsible to recommend, test and implement updates as applicable and approved.
    • Responsible for researching, assisting and resolving issues that pertain to the claims editing software.
    • Responsible for the development and publication of provider reimbursement policies
    • Responsible to work collaboratively, cross organizationally and externally to respond to inquiries and provide education about Neighborhood standards
    • Act as an expert coding resource for the organization
    • Monitor and audit claims editing software for accuracy
    • Other duties 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.



    • Bachelor’s degree or equivalent work experience
    • Three (3) years’ direct application in professional and facility coding
    • Three (3) years’ experience and direct working knowledge of professional and facility billing and reimbursement methodologies
    • Certified Professional Coder certification
    • Strong written and verbal communication skills
    • Demonstrated working knowledge of CMS, Federal and State laws and requirements
    • Proven ability to effectively develop health plan policies
    • Work independently and proactively with minimal direction/supervision
    • Detail-oriented with demonstrated organizational skills and the ability to prioritize in a fast-paced environment
    • Advanced skills in Microsoft Office (Word, Excel, Outlook)


    • Optum CES software experience
    • Claims editing software administration experience
    • Provider relations experience
    • Project management experience

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.

    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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