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Reconsideration Specialist - Certified Professional Coder
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- The Claims Reconsideration Representative relies on the medical notes, benefits, payment policies, clinical medical policies, NCCI edits, coding manuals (CPT, HCPC, ICD-10) to make their determination.
- Responsible to review and resolve provider inquiries related to claim denials and/or bundling edits.
- Responsible for the review of medical notes against the adjudication of services using plan benefits, contractual reimbursement terms and industry standard coding and Neighborhood policies to determine appropriate resolution
- Works in collaboration with Provider Relations to provide claim examples for appropriate provider education
- 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
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