Position Summary:

The Claims Recovery Specialist (“Specialist”) is responsible for processing of all identified claims overpayments within the regulatory and/or contractual timeframes. The Specialist ensure claims overpayments are recovered timely and accurately. The Specialist must understand claims processing requirements which include but not limited to interpretation of contracts and benefits, correct claims coding and billing. The Specialist maintains and track all incoming refunds and overpayment identified internally and by the contracted recovery vendors.

General Duties/Responsibilities:

Essential duties and responsibilities include but are not limited to:

1. Reviews system generated report for potential overpayment and ensure identified claims overpayment is processed timely and accurately
2. Processes identified overpayments in designated recovery database and claims processing system timely and accurately
3. Generates and mails overpayment recovery letter/demand letter and ensures reason for recovery is clearly communicated to provider
4. Responds to provider inquiries, either telephonically or in writing, regarding overpayment refund requests
5. Collaborates with Audit team in ensuring claims payment errors which results in overpayments are recovered timely
6. Collaborates with other department in resolving potential configuration issues and updates on eligibility and other insurance information
7. Researches returned claim checks from providers/vendors, voided checks or letters from providers regarding identified overpayments

1. Assist with implementation and management of contracted overpayment recovery vendors and subrogation
2. Works with recovery vendors in ensuring identified overpayments are accurate
3. Reviews and submits vendor invoices timely and ensure accurate payment request is submitted

1. Reviews overpaid claims and determines if root cause is due to system configuration, training issues or erroneous claims processing 
2. Communicates root causes and issues that impact claims processing quality to Management
3. Generates reports based on recovery findings for training opportunities and process improvements
4. Generates weekly/monthly reports for recovery tracking and trending

1. Meets and consistently maintains productivity and quality standards as defined by Management
2. Actively participates in ongoing training to support company and department initiatives
3. Supports department initiatives in improving processes and workflow efficiencies
4. Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance

Supervisory Responsibilities:

None

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Minimum Requirements:

• Minimum Experience:

• 3+ years claims examining all types of claims (professional, facility, ancillary), preferably in Medicare Advantage delegated model
• 2+ years experience in claims overpayment recovery, preferably in Medicare Advantage setting

• Education/Licensure: 

• High school diploma or general education degree (GED)
• Bachelor’s degree in healthcare management or related field, preferred
• Other:

• Knowledge of claims processing systems (EZCAP preferred)

• Working knowledge of different claims coding requirements, payment methodology (PPS, Medicare fee schedules, etc.), coordination of benefits
• Understanding of Division of Financial Responsibility on how they apply to claims processing
• Intermediate to Advance proficiency in MS Office products – Word, Access and Excel
• Comprehensive knowledge of Medicare Advantage claims processing requirements and other related regulatory requirements
• Knowledge of medical terminology
• Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics
• Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives;
• Demonstrates attention to detail
• Ability to work well in a fast-paced and dynamic environment

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust