Claims Recovery Analyst I

CHPW•Seattle, WA

2d•Remote

About The Position

Responsible for conducting focused claim reviews and identifying and facilitating claim adjustments based on results found through Community Health Plan of Washington claim reviews or as identified by internal Community Health Plan of Washington departments. Responsible for sustaining processes and executing process improvement and quality monitoring. Responsible for contacting providers regarding negative balance collections. Additionally, the role involves investigating and resolving escalated claims issues raised by internal Community Health Plan of Washington (CHPW) departments and committees. The incumbent monitors departmental compliance with state and CMS requirements, including managing the collection and submission of operational performance metrics and required data reporting. Finally, the position serves as a subject matter expert for Claims Recovery, contributing to companywide or specialized projects to improve processes and ensure accurate claims management.

Requirements

Minimum two (2) years claims operations experience required, with proven broad knowledge and execution of quality improvement methods and tools or related experience.
Possess an understanding of the healthcare industry, specifically in the Operations area.
GED or High School diploma or an equivalent combination of education and highly relevant experience in healthcare.
Analytical skills.
Project management skills and team facilitation skills.
Communication skills, both verbal and written.
Technical and process documentation skills.
Ability to work repetitive tasks.
Ability to work well with different people at all levels within the organization.
Ability to analyze, organize and prioritize work, while meeting multiple deadlines.
Complete and successfully pass a criminal background check.
Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.
Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
Vaccination requirement (CHPW offers a process for medical or religious exemptions)
Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Nice To Haves

Experience in managed care preferred.
Medicaid Coordination of Benefits (COB) and Medicare Secondary Payor (MSP) experience preferred.
Prior experience encouraging timely repayment from providers preferred.

Responsibilities

Identify and conduct focused and random claims audits.
Provide research for providers in a negative balance over 45 days.
Create demand letters and support collections effort.
Contacts providers to request refunds.
Regularly submit subrogation referrals.
Facilitate claim adjustments and system remediation as required.
Receive and research escalated claims issues identified by internal Community Health Plan of Washington departments and committees.
Regularly monitor departmental contractual compliance with state and CMS requirements including managing the collection and submission of required operational performance metrics and data reporting requirements.
Participate in companywide or specific projects as a subject matter expert for Claims Recovery.