Claims Recovery Specialist III (Remote)

Resp & Qualifications PURPOSE: Provide validation and analysis of claims overpayments discovered by external claims overpayment recovery vendors, claims processing, audits, and customer service. Provide day-to-day management of active overpayment recoveries and/or overpayment recovery vendors. Responsibilities include validation and analysis of provider audits, and professional, institutional, member, and vendor recoveries. Works with the vendor(s) to approve and implement new recovery concepts. This position will also work closely with the claims, service, financial, and/or payment integrity units to facilitate the adjustment and analyze root causes of overpayment. This can also include third party liabilities, mass tort or class action lawsuit analysis. ESSENTIAL FUNCTIONS: • Performs extensive analysis on medical policies, claim payment policies and contractual obligations for recovery inquiries and requests. Proactively investigates and performs highly complex adjustments as it relates to all cash receipts and voucher retractions. Completes all casework, documenting and summarizing information. Communicates, via phone, with vendors, members and/or providers as it relates to outstanding recovery cases. Identifies and reports problems or trends related to overpayment recovery. Identifies new concepts that will target claim overpayment scenarios. • Provides oversight and support for day-to-day operations of overpayment recovery activities. Oversight includes validation/analysis of completed claims audits, approval and implementation of new overpayment recovery concepts and strategies, tracking of vendor invoice reconciliation and approval. Complete report audit activities monthly and utilizes audit information to ensure audits are conducted timely and effectively, resulting in overall achievement of targeted financial recoveries of the department. • Identifies, researches, and resolves internal and external issues, ranging in complexity, which impact the vendor recovery and/or audit and recoupment programs. Monitors the causes of overpayments to identify trends, issues or other situations that may need further analysis. Works as liaison with Provider Contracting, Member/Provider Service, and our members to ensure that the recovery program operations are consistent with provider contracts as well as federal, state, and local legislative mandates. Prepares and presents information on each audit program. • Coordinate and/or participate in all internal/external meetings relating to the Recovery program and/or Audit and Recoupment programs. Participates with department management in developing and revising other types of recovery programs for the organization. Identify, recommend, and/or implement actions for corporate payment policy improvements based on deficiencies uncovered in the recovery program. • Serves as the primary resource for assisting the Supervisor with training new Claims Recovery Specialists and developing Claims Recovery Specialist?s I?s and II?s. Develops and maintains SOPs for Recovery Programs. QUALIFICATIONS: Education Level: High School Diploma or GED. Experience: • 7 years relevant experience in (healthcare claims reimbursement methodologies, claims, and data analysis). • A working knowledge of CPT/HCPCS coding as well as ICD9-CM diagnoses coding is necessary. Preferred Qualifications: • Prior vendor management, adjustment, audit, and/or recoupment experience. Knowledge, Skills and Abilities (KSAs) • Ability to resolve complex billing issues. • Excellent communication skills both written and verbal. • Excellent follow-up and verification skills. • Ability to maintain effective interpersonal relationships. • 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. Salary Range: $46,296 - $84,876 Salary Range Disclaimer 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 specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements). Department OPM HMO Claims Recovery Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Where To Apply Please visit our website to apply: www.carefirst.com/careers Federal Disc/Physical Demand Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs. PHYSICAL DEMANDS: The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. 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