Claims Recovery Specialist II; Remote

Under minimal supervision, the Claims Recovery Specialist II review and audits medical and/or dental claims to recover payments. Specialist will assist to maximize recovery amounts due to refund of payments made in error to members and/or providers, retro terms and/or focused provider audits. Specialist will provide day-to-day management of active over payment recoveries. This position will work closely with the claims, service, finance, and vendor auditing departments to complete claims adjustments.

Under minimal supervision, the Claims Recovery Specialist II review and audits medical and/or dental claims to recover payments. Specialist will assist to maximize recovery amounts due to refund of payments made in error to members and/or providers, retro terms and/or focused provider audits. Specialist will provide day-to-day management of active over payment recoveries. This position will work closely with the claims, service, finance, and vendor auditing departments to complete claims adjustments.

Under minimal supervision, the Claims Recovery Specialist II review and audits medical and/or dental claims to recover payments. Specialist will assist to maximize recovery amounts due to refund of payments made in error to members and/or providers, retro terms and/or focused provider audits. Specialist will provide day-to-day management of active over payment recoveries. This position will work closely with the claims, service, finance, and vendor auditing departments to complete claims adjustments.

• Under supervision, reviews, audits, and/or initiates recovery efforts for medical, and/or dental claims to recover over payments, ensuring all parts of the process are documented properly.
• Contacts carriers, members and/or providers, via phone, email, and correspondence, to recover and settle overpaid and/or unpaid claims. Responds to carrier, customer and/or provider service inquiries regarding outstanding claims and/or over payment balances. Proactively identifies needs and responds appropriately through investigating, problem solving, engagement of other internal or external resources, and providing high level service. Adjusts claims to reflect cash returned by members and/or providers to reduce and accurately reconcile customer accounts.
• Distributes written correspondence to policy holders to recoup overpaid claims, negotiate repayment agreements when necessary, and ultimately reduce the companys care line. Performs vendor education and training to educate vendors on claims retrieval systems and procedures, general vendor updates.
• Participate in all internal/external meetings relating to Audit and Recoupment. Improves claims audit and recoupment job knowledge by attending training sessions. Participates with department management in revising Audit and Recoupment SOPs.

Education Level: High School Diploma or GED.

Experience:

5 years claims processing.

• 1 year adjustment processing.

• Mathematical ability/aptitude.
• Communication skills.
• Ability to deal with both internal and external clients.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

$42,624 - $78,144

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is…