Analyst, Overpayment Recovery

BlueCross BlueShield of South Carolina•Columbia, SC

1d•Onsite

About The Position

Identifies, researches, and investigates providers for aberrant and abusive billing practices against the company and its subsidiaries. Analyzes hospital accounting records and credit reports for overpayments and fraudulent billing to the corporation.

Requirements

Bachelor’s Degree in a job related field.
3 years-healthcare/hospital management.
3 years-claims analysis/adjudication procedures, trending, or patterns of practices. (may be concurrent).
Analyzes provider contracts
Conducts provider compliance audits
Identifies potential fraud situations
Makes recommendations for corrective actions
Produces monthly summary reports.

Nice To Haves

Experience writing Audit reports.
Medicare Claims Knowledge.
Ability to read Remits and EOBs.
Ability to hold conference calls with Senior Management both internally and externally.
Ability to interpret and understand MSP requirements as they are found in the CMS IOMs.

Responsibilities

Conduct onsite audits of hospitals and provider facilities to identify overpayments and compliance with government regulations, which may include Medicare Secondary Payer (MSP) regulations.
Analyze provider contracts to determine the proper reimbursement of inpatient and outpatient benefit payments and calculates correct refunds.
Perform comprehensive review and responds to complex inquiries of all varieties of provider facilities. This may include the review, trending, analysis, and executive report of all claims actions.
Identify potential fraud and abuse situations and refers documented findings to appropriate area for investigation.
Develop comprehensive financial strategies and master audit programs for hospitals and provider reviews.
Conduct outreach workshops and training sessions for appropriate groups to focus on problem areas relating to government regulations and billing issues.
May coordinate research and reporting functions for the MSP prepay claims department.