Claims Recovery Analyst

Claim Recovery Analyst

Overall Purpose:

The main function is identifying and processing all overpayments/underpayments identified internally or through interface with third party recovery vendors for professional and/or facility claims in accordance with local, state, federal guidelines, health plan and provider contracts.

Education and Experience:

• High school diploma or GED. Some college preferred

• Recovery Analyst must have five (5) years minimum experience in the Medical Claims payment industry specializing in payment and audit of professional and facility claims

• Must have analytical and problem-solving skills

• Must be able to perform root cause analysis and present findings

• Must be nimble with policy and priority changes

Knowledge, Skills and Abilities:

• Knowledgeable of any local, state and federal rules regarding the adjudication of medical benefits.

• Personal computer with main frame emulation, claims management software, word processing and management software, Imaging retrieval software, fax machine, copy machine, basic office aids.

• Working knowledge of HMO operations, claims delegation compliance, and contract interpretation.

• Knowledge of CPT, HCPCS, ICD-10, DRG and APC coding and CMS Guidelines.

• Strong organizational and time management skills with the ability to prioritize individual workloads.

• Strong analytical and interpersonal skills

• Strong and effective communication and presentation skills

Essential Functions:

• Responsible for all actions/responsibilities as described in company-controlled documentation for this position

• Contributes to and supports the corporation's quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation's quality improvement efforts

• Conduct pre and post payment audit of professional and facility claims for accurate payment per contract, health plan, State and Federal requirements

• Run and analyze reports to identify professional and facility claim over-payments/under-payments and initiate recovery

• Interface with third party recovery vendors to identify over-payments, underpayments, and initiate recovery. Maintain recovery records per vendor and provide review of invoices for payment to management

• Answer questions for customer service regarding overpayment and underpayment recoveries

• Perform adjustment adjudication for claims under-paid, over-paid, or in some other fashion incorrectly adjudicated

• Contributes to and supports the corporation's quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation's quality improvement efforts

• Execute other duties as assigned by manager

• Track and trend billing errors and identify fraud, waste, and abuse

• Present to leadership as needed on recovery outcomes and projections

Pay range: $23.00-28.94/hr + bonus opportunity + rich benefits plan