Analyst Part C/D & Recovery

Blue Cross Blue Shield•Detroit, MI

42d•$54,000 - $90,500

About The Position

SUMMARY: The Analyst applies analytical skills and specialized knowledge to identify Medicare Part C/D members with other primary health information and pursue recovery of associated claim overpayments. The position is responsible for establishing, updating, and/or correcting Part C/D coordination of benefits (COB) records by utilizing knowledge of the Centers for Medicare and Medicaid (CMS), Medicare Secondary Payer (MSP) rules, and Part C/D Medicare plan requirements. The role also supports claim overpayment recovery and reconciliation efforts. Research and analyze data to support the reconciliation and restoration of MA plan payment reductions due to MSP status. ESSENTIAL DUTIES AND RESPONSIBILITIES Other duties may be assigned. • Verifies and reconciles provider/vendor identified claim overpayments. Updates records and prepares responses to providers. • Researches and analyzes MA Plan payment data, CMS COB data, OHI records, and CMS ECRS system to determine the validity of MSP plan payment reductions and completes actions to restore premium reductions. • Supports the recovery of aged account receivables due to medical claim overpayments. • Investigates Part C/D COB data and eligibility leads to identify potential COB, verify other health information, and establish MSP coordination periods. Adds, updates and/or corrects OHI records in pharmacy and medical claims processing systems including submitting COB data to CMS. • Processes and reconciles Part D COB notification responses, and updates records accordingly. • Analyze medical and pharmacy data to identify and pursue claim recoveries from other carriers, providers, and members, including corresponding claim and member detail, and coordinates follow up with other carriers, members, providers, and CMS as appropriate. • Prepares, tracks, and delivers validated claim adjustment requests to appropriate vendor. • Receives and reconciles recovery responses related to overpayments including other carrier coverage and changes in member enrollment data. • Loads and processes checks related to recovery of overpayments. Reconciles claim adjustments and cash received to recovery submissions. • Researches and locates CMS and/or internal policies to ensure compliance. EDUCATION AND EXPERIENCE Relevant combination of education and experience may be considered in lieu of degree.

Requirements

Bachelor's degree in Business Administration, Economics, Health Care, Information Systems, Statistics, or a related field.
One year experience in a related field typically in at least two of the following areas/settings: health insurance, health plan operations, analysis, financial reconciliation, claim payment and recovery.
Ability to identify/pursue claim recoveries and reconcile claim refund payments to identified claims. Must maintain 98% accuracy.
Ability to independently research and analyze data.
Excellent written and oral communication skills.
Familiar with operating desktop PC, laptop, and various printer/fax machine models and multi functional devise machinery.
Experience with direct customer interface including providers, members and other health plans.
Experience with Microsoft Office products including Word, Excel, and Access.

Nice To Haves

Certification or progress toward certification is highly preferred and encouraged.
Prior Part C/D COB experience preferred.
Experience verifying coverage with carriers and applying MSP rules is preferred.
Experience posting and reconciling claim refunds is preferred.
Experience with claim payment recovery is preferred.
Experience with Microsoft Access using form entry and executing queries is desired.
Knowledge of MA plan operations and Part C/D recovery processes is preferred.
Knowledge of CMS compliance guidelines, MAPD plan requirements related to COB and CMS MSP regulations.
Ability to apply MSP regulations and make valid MSP determinations for group and non-group health plan coverage.
Knowledge of and/or ability to research, interpret and apply Medicare and BCBSM MA Part C/D COB policies.
Experience with NASCO is preferred.

Responsibilities

Verifies and reconciles provider/vendor identified claim overpayments. Updates records and prepares responses to providers.
Researches and analyzes MA Plan payment data, CMS COB data, OHI records, and CMS ECRS system to determine the validity of MSP plan payment reductions and completes actions to restore premium reductions.
Supports the recovery of aged account receivables due to medical claim overpayments.
Investigates Part C/D COB data and eligibility leads to identify potential COB, verify other health information, and establish MSP coordination periods. Adds, updates and/or corrects OHI records in pharmacy and medical claims processing systems including submitting COB data to CMS.
Processes and reconciles Part D COB notification responses, and updates records accordingly.
Analyze medical and pharmacy data to identify and pursue claim recoveries from other carriers, providers, and members, including corresponding claim and member detail, and coordinates follow up with other carriers, members, providers, and CMS as appropriate.
Prepares, tracks, and delivers validated claim adjustment requests to appropriate vendor.
Receives and reconciles recovery responses related to overpayments including other carrier coverage and changes in member enrollment data.
Loads and processes checks related to recovery of overpayments. Reconciles claim adjustments and cash received to recovery submissions.
Researches and locates CMS and/or internal policies to ensure compliance.