Cost Avoidance Specialist

Overview

Under the direction of the Cost Avoidance Supervisor, the Cost Avoidance Specialist I monitors activities related to cost savings and recoveries of medical claim payments; identifies and verifies members other health coverage (OHI), updates system and recovers over payment, and researches and validates provider refund checks. The Cost Avoidance Specialist interfaces with all departments in an information sharing capacity to promote proper payment procedures and timely cost effectiveness in claims payments.

• Assess, implement, and monitor activities related to recoveries and cost savings of medical claims with duties including but not limited to:
• Perform assessments and identify potential over payments on claims related to all lines of business;
• Research and identify over payments related to over utilization of procedures, billing procedures, potential fraudulent claims, duplicate payments, and over payments due to lack of coordination of benefits with member's primary health care insurance policy such as a private health insurance, Medicare coverage, or an open case with CCS;
• Perform recovery activities associated with claim audit findings;
• Report dollar amounts identified for recovery, recovery amounts received, and reasons for over payments;
• Responsible for identifying via reports, Medi-Cal over payments due to retro-active Medicare or Third Party coverage and the recoupment of same.
• Research and process all Partnership product lines for COB and Third Party Liability (TPL) recoveries and communicate outcome with Cost Avoidance Supervisor.
• Prepare reports as per requirements of Department of Health Care Services (DHCS) and other regulatory or auditing agencies for Cost Avoidance Supervisor review.
• Assist with research, analysis and reports of claims as requested by management.

Researches and validates all provider refund checks received with duties including but not limited to:

• Identifies if refund check received is due to Partnership, reason for the refund;
• Identifies configuration or training issues related to the payment received;
• Recommends appropriate actions, statistical or regular adjustment, completes adjustments and reports outcome to Cost Avoidance Supervisor.
• Researches and validates other health insurance coverage of Partnership members with duties including but not limited to:
• Reviews claims routes and identifies other insurance via attachments provided.
• Utilizes call center, Trans Union or DHCS website to validate the active status and type of insurance.
• Updates Amisys appropriately based upon the type, coverage dates and scope of coverage.
• Prepares reports and notification to providers of potential recovery if the insurance is found to be retroactive.

SECONDARY DUTIES AND RESPONSIBILITIES

Other Duties as Assigned

Education and Experience

High School Diploma or equivalent and minimum two (2) years’ experience in health care including experience in processing claim in an automated claims environment, working knowledge of medical terminology, and related procedure and diagnostic coding (CPT-4, ICD-9, ICD-10, HCPCS); or equivalent combination of education and experience. Experience in Medi-Cal operations, Amysis, COB, Reinsurance, and claims billing procedures preferred.

Special Skills, Licenses and
Certifications

Ability to accurately and efficiently perform 10-key by touch required and working knowledge of windows-based PC applications including word processing, spreadsheets, and database management; ability to use MS Word and Excel required. Must possess excellent organizational skills and excellent problem solving skills. Must be proficient in math skills. Valid California driver’s license and proof of current automobile insurance compliant with Partnership…