The Claims Recovery Coordinator will be responsible for auditing and coordinating the processing of all refunds requests and refunds received as it relates to FFS claims payment for each IPA/Capitated Hospital/Health Plan. The primary function of the Claims Recovery Coordinator will audit claims data for payment accuracy, bill providers for claim overpayments, process and post recovery on the claim, and ensures adherence to compliance policies. Auditing of claims data will include, but is not limited to: Duplicate Payments, Eligibility issues, Contract/Fee Schedule issues, Other Coverage issues, Coordination of Benefits, Health Plan Cap Deductions, Stoploss Re-insurance, Health Plan Incentive Programs, and other areas as defined.

Responsibilities:

• Review, Sort, process and audit all appropriate paperwork for Insurance, government, patient and Non-A/R refunds including researching and corresponding on missing payments, misdirected and unidentified payments, returned refunds and maintaining accounts.
• Maintain and reconcile accounts based on the daily refund log.
• Researches and documents denial and refund determinations at all levels of provider reconsiderations/appeals in a thorough, professional and expedient manner.
• Verify the refund check or debit offset is properly applied to the appropriate claim in the applicable System.
• Obtain all available data relevant to the investigation of potential claim overpayment.
• Utilize auditing tools to identify and determine accuracy of claims payments (prospectively and retrospectively).
• Composes all correspondence in accordance with regulatory requirements, to reflect accurate information in a clear, concise, grammatically correct format.
• Maintain well-organized, accurate and complete files for future reference.
• Interfaces with internal departments and external resources and organizations.
• Conducts all pertinent research to evaluate, respond and close incoming written practitioner appeals and reconsiderations accurately, timely and in accordance with all established regulatory guidelines.
• Acts as point of contact for submission and/or resolution of denial and refund determinations, practitioner appeals, and interfaces with Payers and/or Client Services in regards to Payers and/or Member reconsiderations, disputes and/or appeals.
• Completes appropriate documentation for tracking/trending data.
• Provide regular feedback to the Claims Management concerning process improvement opportunities, or any training opportunities relative to adequacy of file investigation/ development in advance of the recovery effort.
• Produce month end spreadsheet and supplemental summary reports to facilitate Revenue reporting to Claims Management.

Qualifications:

• HS Diploma or GED
• Minimum two years’ experience in payment posting, insurance follow-up, understanding of insurance rules and benefits, customer service.
• Previous claims refund experience preferred.
• Experience in a managed care setting.
• Experience in EZCap /SHARE claims modules.
• Experience with Medi-Cal claim rules.

Skills and Abilities:

• Intermediate to advanced word processing, spreadsheet, presentation, and internet skills.
• Expert-level working knowledge of complex billing and documentation regulations, with the ability to research additional topics when necessary.
• Strong analytical, detail-oriented skills with a firm understanding of healthcare operational processes and technology concepts.
• Ability to express complex issues in clear and concise written and verbal updates, reports, and recommendations.
• Ability to maintain the highest standards of confidentiality and to work with a high degree of integrity to perform objective and constructive audits.
• Strong investigative and project management skills.
• Highly motivated with great organizational skills and the ability to multitask, handling interruptions and achieving deadlines.
• Demonstrates a results-oriented approach for delivering service in an accurate, complete, and timely fashion.
• Demonstrate success working both individually and with a team in a fast-paced, high volume, deadline oriented environment with emphasis on accuracy and timeliness.
• Excellent communication skills, both oral and written, in order to deal effectively with a variety of interpersonal relationships and situations.
• Ability to follow up on pending issues and meet deadlines.
• Ability to cultivate strong working relationships with personnel from various areas of responsibility within the organization and interact with employees, customers and vendors in a professional manner.
• Type 45+ WPM
• Positive approach, can-do attitude, flexibility and ability to operate with grace under pressure
• Computer literacy and proficiency in programs such as Microsoft Excel and Word
• High attention to details and strong organization skills is critical.
• Ability to manage multiple tasks, prioritize, and meet deadlines consistently.
• General business equipment (copier, printer, fax, and scanner).
• Demonstrated success working both individually and with a team in a fast-paced, high volume, deadline oriented environment with emphasis on accuracy and timeliness.
• Strong work ethic and attention to detail is required.
• Detail oriented, professional attitude, reliable.
• Ability to follow up on pending issues and meet deadlines.
• Possess strong organizational and time management skills
• Ability to cultivate strong working relationships with personnel from various areas of responsibility within the organization and interact with employees, customers and vendors in a professional manner.

Job Type: Full-time

Pay: Up to $23.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Physical setting:

• Office

Schedule:

• 8 hour shift

Ability to commute/relocate:

• Montebello, CA 90640: Reliably commute or planning to relocate before starting work (Required)

Work Location: Hybrid remote in Montebello, CA 90640

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