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
