Specialist, Claims Recovery (Remote)

Claims Recovery Specialist

Provides support for claims recovery activities including researching claim payment and billing guidelines, audit results, and federal regulations to determine overpayment accuracy and provider compliance. Collaborates with health plans and vendors to facilitate recovery of outstanding overpayments. Monitors and controls backlog and workflow of claims and ensures that claims are settled in a timely fashion and in accordance with cost-control standards.

Essential Job Duties

Prepares written provider overpayment notifications and provides supporting documentation such as explanation of benefits (EOBs), claims and attachments.

Maintains and reconciles department reports for outstanding payments collected, past-due overpayments, uncollectible claims and autopayment recoveries.

Prepares and provides write-off documents that are deemed uncollectible, and ensures collections efforts are exhausted for write-off approval.

Researches simple to complex claims payments using tools such as Department of Health and Human Services (DSHS) and Medicare billing guidelines, Molina claims processing policies and procedures, and other resources to validate overpayments made to providers.

Completes basic validation prior to offset to include, eligibility, coordination of benefits (COB), standard of care (SOC) and diagnosis-related group (DRG) requests.

Enters and updates recovery applications and claim systems for multiple states and prepares / creates overpayment notification letters with accuracy; processes claims as a refund or auto debit in claim systems and in recovery application.

Follows department processing policies and procedures including, claims processing (claim reversals and adjustments), claim recovery (refund request letters, refund checks, claim reversals), and reporting and documentation of recovery as explained in departmental Standard Operating Procedures (SOPs).

Responds to provider correspondence related to claims recovery requests and provider remittances where recovery has occurred.

Collaborates with finance to complete accurate and timely posting of provider and vendor refund checks and manual check requests to reimburse providers.

Supports claims department initiatives to improve overall claims function efficiency.

Meets claims department quality and production standards.

Completes basic claims projects as assigned.

Required Qualifications

At least 1 year of experience in a clerical role in a claims, and / or customer service setting - preferably in managed care, or equivalent combination of relevant education and experience.

Research and data entry skills.

Organizational skills and attention to detail.

Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.

Customer service experience.

Effective verbal and written communication skills.

Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

Claims recovery experience.

Health insurance experience in a managed care setting.