Claims Recovery

Decton Staffing Services






Job Summary

The position is responsible for performing recoveries on claims that have been overpaid, and must understand and adhere to recovery regulations mandated by Company policies and AB1455, CMS, DHCS, DMHC regulations. The incumbent will provide guidance on transactions, inquiries and complaints from both internal and external customers related to overpayment issues. The position oversees and implements quality improvement activities from trend reports, and works closely with management to identify training opportunities. 

Position Responsibilities

  • Review and analyze system generated reports to determine recovery opportunities.
  • Keep current on CMS, DHCS, DMHC regulations and Company Policies and contracts or letters of agreement language as it pertains to recovery.
  • Communicate effectively with management to create a follow through plan to resolve recovery cases.
  • Assist with implementation and management of any third party vendor utilized for recovery, pre-payment claims review or subrogation.
  • Initiate and expand recovery opportunities through audits, process enhancements and provider calls in addition to system generated reports.
  • Analyze errors that result in recovery of money to determine their root cause.  The Claims Specialist is responsible to identify additional recovery opportunities related to the root cause.
  • Analyze previous processed claims data to determine Provider Dispute Resolution required and ensure that correct payments are released and advise recovery unit supervisor if claim resulted in payment error.
  • Communicate to providers clearly regarding guidelines and the reason for the refund request.
  • Identify and report inconsistencies relative to the adjudication of claims for contract compliance.
  • Prepare and communicate issues and resolutions to Management.
  • Answer provider questions regarding recovery based upon contractual and/or Company agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.
  • Alerts management of issues that impact quality, i.e. incorrect database configurations, etc.
  • Compile monthly reports based on research identifying opportunities for training, desktop revisions or process improvements.
  • Compile monthly reports for supervisor outlining monthly recoveries performed.
  • Other projects and duties as assigned by management.

Possess the Ability To:

  • Handle multiple tasks and meet deadlines.
  • Develop and maintain effective working relationships with all levels of staff and providers.
  • Effectively utilize computer, Company claims processing system, and appropriate software (Excel/Word/Access) as needed.
  • Keeps closely attuned to the needs and perspectives of customers and uses this insight for the benefit of the business.
  • Meet clearly stated expectations and take responsibility for achieving results.
  • Research and identify issues and problems, develop solutions, and prepare recommendations, including policies and procedures.
  • Effective written and verbal communication.
  • Effectively utilize computer and appropriate software and interact as needed with Company Claim Processing Systems.

Experience & Education

  • High School graduate or equivalent required.
  • 2+ years of experience processing on-line Professional and Facility claims in a managed care and/or PPO/indemnity environment required.
  • 2+ years of experience communicating with provider in relation to recoveries required.
  • Experience processing Medicare or Medi-Cal claims required.
  • Medical Coding/ Billing experience preferred.
  • Must have good customer service skills required.
  • Proficient in Excel and Access preferred.

Knowledge of:

  • Principles and practices of managed health care, health care systems.
  • Principles and techniques for handling customer relation issues.
  • AB1455 Guidelines and regulations
  • Revenue Codes, CPT-4/HCPCS, ICD and Medi-Cal codes.
  • CMS-1500 and UB claim forms.
  • Industry pricing methodologies, such as RBRVS, Medicare/Medi-Cal Fee Schedule, etc.
  • Contract language interpretation.
  • Medical Terminology.
  • Benefit interpretation and administration.
  • Medicare/Medi-Cal guidelines and regulations as they pertain to recovery.
  • Personal Computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
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