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Claims Reconsideration Specialist

Philadelphia, 901 Market Street, Philadelphia, Pennsylvania, United States of America Req #885
Tuesday, September 25, 2018
We are proud to be an EEO/AA employer M/F/D/V. Minority and women are encouraged to apply. We maintain a drug-free & nicotine free workplace and perform pre-employment substance abuse testing.

Position Summary


Responsible for the resolution of provider claim reconsideration requests, member billing complaints and related issues involving claim adjustment processing via correspondence, portal requests or projects submitted by providers.




  • Handle and resolve claim inquiries, complaints and appeals received from providers.

  • Adjudicate claim adjustments on line while servicing the provider.

  • Resolve all assigned claim reconsideration requests through MACESS, including completing any correspondence directed to external or internal entities.

  • Process routine claim adjustments resulting from external inquiries, other internal department referrals and claim quality review efforts in a timely manner according to established guidelines.

  • Investigate and facilitate timely resolution on suspense conditions using MACESS service forms within 48 hours of receipt.

  • For reconsideration requests submitted on excel spreadsheets, document outcome of appeal in designated fields by timelines assigned by Team Leader or Supervisor.

  • Analyze claims adjudicated in error, making recommendation to Supervisor or Team Leader for process improvements.

  • Meet production and quality expectations for the department.  Properly document all claim review activity through application of hold codes.

  • Provide accurate and complete information in response to providers’ claim inquires.

  • Receive a score of 90% or better on monthly quality audits measuring courtesy, listening, communication, knowledge and documentation.

  • Assist the unit in meeting and maintaining performance standards, such as 10% or less call abandon rate, 30 seconds or less average answer delay and 80% or higher service level.




Minimum of three years of claim processing, medical billing, or medical coding experience.

Minimum of one year customer service experience.

Excellent communication skills; with the ability to write a comprehensive letter of particular importance.

Knowledge of CPT-4, HCPCS and ICD-9 coding schemes.

General understanding of the principles of managed care.

High School diploma

Medicare Advantage Compliance Statement:  Compliance with all applicable rules, regulations and laws is a condition of employment.  Employees must read and sign, both the Business Code of Conduct and the Personal Standard Code of Conduct, and are expected to perform their duties ethically and honestly.

Access To Protected Health Information:

Other details

  • Pay Type Hourly
  • Required Education High School
  • Philadelphia, 901 Market Street, Philadelphia, Pennsylvania, United States of America