Claims Operations Recovery Spec III

Elevance Health • Norfolk, VA

3d • Remote

About The Position

Claims Recovery Specialist III Location: Richmond, Roanoke or Norfolk, VA Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending. The Financial Operations Recovery Specialist III is responsible for the discovery, validation, recovery, and adjustments of claims overpayments. May do all or some of the following in relation to cash receipts, cash application, claim audits, collections, overpayment vendor validation, and claim adjustments. How you will make an impact: Primary duties may include, but are not limited to: Audits paid claims for overpayments using various techniques including systems-based queries, specialized reporting, or other research. Interacts with staff and management from other departments on a regular basis to ensure customer satisfaction. Responsible for validating Provider/Member Outstanding checks, and Escheat Checks. Responsible for requesting overpayment (Interest/Prompt Pay). May work with recovery and collection vendors to validate overpayment, validate vendor invoices and provide feedback to modify queries when needed. Works closely with contract managers to identify and correct contractual issues, if applicable. Handles complex case research and resolution. May perform collection activities to ensure the recovery of overpayments and maintenance of unprocessed cash and accounts receivable processes and all other cash applications as required. May review and monitor associates work for quality standards. May review department policy and procedure manuals for accuracy and works to ensure procedures and polices are accurate and complete. Assists in special projects to find and prevent overpayments and to identify process improvements. Completes special projects as assigned with minimal supervision. Researches voluntary refunds for accuracy. Requires accurate balancing of all accounts. Assist Lead with weekly reports and training.

Requirements

• Requires a H.S. diploma or equivalent and a minimum of 4 years of claims processing and/or customer service experience; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

• AA/AS or higher level degree preferred.
• 4 plus years of all Claims processing experience of these systems (WGS, Facets, CHIPS, CS90, Nasco, BlueSquare)
• Proficiency in Anthem Claims Recovery (ACR); Claims Overpayment Recovery (COR); WellPoint Content Frameworkk (WCF); Business Distributor System (BDS); and Check inquiry.

Responsibilities

• Audits paid claims for overpayments using various techniques including systems-based queries, specialized reporting, or other research.
• Interacts with staff and management from other departments on a regular basis to ensure customer satisfaction.
• Responsible for validating Provider/Member Outstanding checks, and Escheat Checks.
• Responsible for requesting overpayment (Interest/Prompt Pay).
• May work with recovery and collection vendors to validate overpayment, validate vendor invoices and provide feedback to modify queries when needed.
• Works closely with contract managers to identify and correct contractual issues, if applicable.
• Handles complex case research and resolution.
• May perform collection activities to ensure the recovery of overpayments and maintenance of unprocessed cash and accounts receivable processes and all other cash applications as required.
• May review and monitor associates work for quality standards.
• May review department policy and procedure manuals for accuracy and works to ensure procedures and polices are accurate and complete.
• Assists in special projects to find and prevent overpayments and to identify process improvements.
• Completes special projects as assigned with minimal supervision.
• Researches voluntary refunds for accuracy.
• Requires accurate balancing of all accounts.
• Assist Lead with weekly reports and training.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees