• Claims Reconsideration Representative

    Job Locations US-RI-Smithfield
    Req No.
    NHPRI Department
    700 - Claims
    Regular Full-Time
  • Overview

    This position is responsible to provide consistent, single point of contact service to our provider network concerning issues and inquiries related to claims edit determinations and requests for separate reimbursement.  The representative is also responsible for triage of issues which require escalation.


    • Responsible for the review and adjudication of services flagged by claims editing software within the claims transactional system, according to plan benefits, contractual reimbursement terms and industry standards
    • Responsible for review and resolution of provider correspondence related to claim denials generated by claims editing software
    • Responsible for review and resolution of customer service issues related to claims reimbursement edits
    • Responsible for analysis and recommendations to increase the automation of claims edits
    • Responsible for identification and review of repetitive and/or inaccurate billing practices on a claim submission and/or content level. This includes data mining rejected claim submissions, adjudicated claims as well as a review of all claims that have flagged for a data submission warning errors
    • Responsible for identification and review of potential overpayments of claims
    • Responsible for determining if correct billing/coding requirements have been met including but not limited to; service to diagnosis compatibility, patient and provider demographic compatibility, revenue to service code compatibility, claim form field data validity
    • Responsible for outreach to providers to promote provider education via written and verbal correspondence
    • Responsible for recommendations for areas of provider claim submission and/or billing and reimbursement education
    • Responsible for triage of potentially fraudulent or abusive billing patterns to the Claims Auditing Unit
    • Responsible for triage of configuration issues
    • Develop and maintain cumulative reports and spreadsheet
    • Retroactive adjustment and other special projects, as assigned
    • 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



    • High school graduate or equivalent
    • Three (3) to Five (5) years of direct application of coding, billing and reimbursement mechanisms via claims processing and/or medical billing experience
    • American Academy of Professional Coder’s Certification(s) or American Health Information Management Association’s Certified Coding Specialist
    • Prior experience with claims editing software
    • Demonstrated working knowledge of medical record documentation requirements and interpretation as it relates to claim reimbursement
    • Experience communicating with provider networks both verbally and in print
    • Demonstrated experience in data collection, presentation and action plans
    • Demonstrated ability to effectively prioritize and execute tasks and special projects
    • Demonstrated ability working with Microsoft Suite (Word, Excel)
    • Strong verbal written communications skills
    • Ability to work both independently and as a team member


    • Some college level up to a Bachelor’s degree
    • Related Professional Training and/or Certifications
    • Prior experience within a claims operations area in a Health Care environment
    • Working knowledge of Fraud and Abuse Policies and Practices

    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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