• Claims Service Recovery Representative

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

    Responsible for the day to day managing of provider issues and concerns.  Acts as a liaison/advocate between the provider network and internal departments. Works directly with practice managers, billing agencies, and physicians via phone, email or in-person to assist in resolving challenges.  He/she is responsible for managing all operational aspects of the provider relationship. This will include assigned and unassigned accounts.


    He/she will serve as SME for the network and will be responsive for all incoming inquiries (for all channels, phone, e-mail, mail) regarding current claims, escalated issues, and strategic planning. 


    He/she works collaboratively with business and operational units such as Claims Production, Provider Claims Services (call center), Quality Control, and Reconsideration Specialist to ensure proper and cohesive claims communication to providers. Acts as the lead point of contact for any and all matters specific to customers and claims that have been escalated.


    He/she assumes ownership and accountability for the timely and accurate identification and resolution of claims issues through reporting, research, and testing.


    • Serves as the subject matter expert and lead on functional deliverables ensuring optimal efficiency in all areas of responsibility; Tracks and maintains all known issues and implements work plans to improve claims accuracy and systemic issues that decrease efficiency or provider satisfaction.
    • Receives, tracks, completes and maintains the provider grid process on a daily basis providing timely claims determination and feedback to providers
    • Receives, tracks, completes, and maintains the case rate report on a daily basis providing timely claims determination and feedback to providers
    • Receives correspondence on escalated issues
    • Monitors provider grid submission for proactive identification of potential issues
    • Develops and implements work process improvements; Serves as phone back up for Provider Claims Services call center
    • Partners to create desktop procedures in conjunction with training specialists for team members to work efficiently and consistently
    • Cultivates strong business relationships with provider community ensuring that network providers receive appropriate and timely responses
    • Ensures the satisfactory resolution of operational issues with provider community. Attends ad hoc meetings and regularly scheduled operational meeting with provider community
    • Works in collaboration with IT teams to ensure root cause analysis is clear for all issues; Supports testing of new functions, features, system upgrades, new implementations
    • 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 experience
    • One (1) to Three (3) years’ experience with a managed care organization or a health care related organization (HMO; Medicaid/Medicare)
    • One (1)+ years’ experience working in direct relation with a provider community (call center, contracting, etc.)
    • Demonstrated understanding and experience in all aspects of claims adjudication, processing, and analysis
    • Ability to manage multiple projects simultaneously
    • Demonstrated experience with managing and cultivating strong business relationships with provider community
    • Ability to understand business systems and articulate deficiencies and opportunities
    • Understanding of provider reimbursement mechanisms
    • Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
    • Basic understanding of contract implementation and working knowledge of contract language



    • CPC Certification
    • 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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