Resp & Qualifications

PURPOSE: 
Under minimal supervision, the Claims Recovery Specialist II review and audits medical and/or dental claims to recover payments. Specialist will assist to maximize recovery amounts due to refund of payments made in error to members and/or providers, retro terms and/or focused provider audits. Specialist will provide day-to-day management of active overpayment recoveries. This position will work closely with the claims, service, finance, and vendor auditing departments to complete claims adjustments.

ESSENTIAL FUNCTIONS:

• Under supervision, reviews, audits, and/or initiates recovery efforts for medical, and/or dental claims to recover overpayments, ensuring all parts of the process are documented properly.
• Contacts carriers, members and/or providers, via phone, email, and correspondence, to recover and settle overpaid and/or unpaid claims. Responds to carrier, customer and/or provider service inquiries regarding outstanding claims and/or overpayment balances. Proactively identifies needs and responds appropriately through investigating, problem solving, engagement of other internal or external resources, and providing high level service. Adjusts claims to reflect cash returned by members and/or providers to reduce and accurately reconcile customer accounts.
• Distributes written correspondence to policy holders to recoup overpaid claims, negotiate repayment agreements when necessary, and ultimately reduce the company's care line. Performs vendor education and training to educate vendors on claims retrieval systems and procedures, general vendor updates.
• Participate in all internal/external meetings relating to Audit and Recoupment. Improves claims audit and recoupment job knowledge by attending training sessions. Participates with department management in revising Audit and Recoupment SOPs.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Experience: 5 years claims processing.

Preferred Qualifications:

• 1 year adjustment processing 

Knowledge, Skills and Abilities (KSAs)

• Mathematical ability/aptitude.
• Communication skills.
• Ability to deal with both internal and external clients.
• 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: $42,624 - $78,144

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).

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.

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.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship