Claims Recovery Specialist II (Remote)

CareFirst•Baltimore, MD

1d•Remote

About The Position

Under minimal supervision, the Claims Recovery Specialist II reviews and audits medical and/or dental claims to recover payments. The 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. The 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.

Requirements

High School Diploma or GED
5 years claims processing
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.
Must be eligible to work in the U.S. without Sponsorship

Nice To Haves

1 year adjustment processing

Responsibilities

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.