Claims Receivables and Recovery Specialist

Job Description Summary The Claims Receivables and Recovery Specialist reports to the Supervisor, Payment Integrity, and works with various departments within the company to ensure all open claim receivables, which are results of claim over payments and/or adjustments, are pursued and collected appropriately. The position is responsible for appropriate approvals, presentations of the receivables for decisions, and process documentation.

Duties And Responsibilities Receivable & Recovery Support Research, review and analyze all over payments, refunds and voids relating to medical, dental, and vision claims.

Collect receivables for the Western Growers Assurance Trust (WGAT) and clients of the Third-Party Administrator (TPA) that may be a result of over payments or claims adjustments by researching, writing letters, and actively making phone calls.

Process refunds and perform voids and reissues as deemed necessary.

Review, research and analyze statistical data relating to claim history.

Research and respond to inquiries from other departments related to claim financial transactions within the required agreed upon turn-around-time.

Reporting Run claim open receivables report to review for new and past due over payments.

Prepare a monthly report to the management team which provides consistent activity, tracking and performance measures as a result of collections, over payments, refunds, voids, and allocation of all monies received.

Prepare reports for accounting to handle processing, approvals for adjustments, void, refunds.

Assure all documentation is categorized, approvals file and archived upon demand.

Support, analyze and prepare for auditors and the requested information on a timely manner.

Prepare presentations of data, clients files, and analysis to obtain approvals to adjust over payments accordingly.

Process Improvement Identify and document root causes of claim over payments.

Provide claim over payment remediation recommendations.

Participate in ongoing process reviews to eliminate and/or decrease open receivables.

Other Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.

Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.

Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.

Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).All other duties as assigned.

Physical Demands/Work Environment The physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office.

The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.

Qualifications High school education or equivalent and two (2) years of experience adjudicating medical/dental claims and handling claims recoveries.

One (1) year of collections experience preferred.

Accounting or Receivables background preferred.

Knowledge of Current Procedural Terminology (CPT) and International Classification of Diseases 10th Revision (ICD-10) and medical terminology.

Exceptional knowledge of end-user office software (e.g., Microsoft Office), with particular emphasis on Excel spreadsheets and summary analysis.

Exceptional understanding and interpretation of financial transaction and receivables systems.

Proven ability to manage timelines and commitments independently.

Excellent verbal and written communication skills.

Ability to apply critical thinking and demonstrate sound judgement in a variety of situations.

Strong attention to detail.

Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.

Home router with wired Ethernet (wireless connections and hotspots are not permitted).A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)A functioning smoke detector, fire extinguisher, and first aid kit on site.
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