Payment Integrity Data Mining/Recovery Specialist

Blue Cross and Blue Shield of Nebraska

8d•Hybrid

About The Position

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve. Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community. The ideal candidate will live within driving distance of the Omaha, Nebraska office. This position allows remote flexibility but may have in-office collaboration and meetings. If living in one of our approved states (Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas) – this person may travel to our headquarters. This position is responsible for reviewing and researching all findings from our Payment Integrity (PI) vendors and driving awareness to mitigate future claim overpayments. The individual will reconcile PI vendor monthly billing by maintaining accurate records of all PI vendor accounts, investigate new data mining overpayment concepts for our internal PI team, and recover overpayments that cannot be offset by providers and/or members via outreach communications. In addition, this person will be responsible for quantifying and validating prepay and post pay claims for BCBSA InterPlan and will invoice for vendor fees of PI activities BCBSNE performs for other host Blues Plans.

Requirements

High School Diploma or equivalent and two (3) years of experience in a health insurance field.
An equivalent combination of education and experience may be substituted for this requirement.
The ability to meet or exceed the attendance and timeliness requirements of their departments.
The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.

Nice To Haves

One (1) year refund, Payment Integrity, and/or auditing experience.

Responsibilities

Works closely with PI vendors and internal business partners to respond to inquiries and determine opportunities to ensure mitigation of future overpayments.
Analyzes individual vendor files, sends approved overpayments to appropriate adjustment areas and researches any discrepancies between what was identified and the adjustments.
Reconciles all PI vendor bill submissions to ensure accuracy and avoid duplicate payments.
Maintains files of all identified PI vendors to ensure claims have been adjusted and money has been recuperated.
Audits internal data mining concepts to identify and recover overpayments.
Research and completes outreach to providers/members to communicate and obtain manual overpayment refunds that cannot be systematically recovered.
Provides timely and accurate investigation of potential overpaid claims identified by recovery vendors.
Compiles, reconciles, and validates all prepay and post pay PI activities performed on Host claims on a regular cadence to invoice for PI vendor fees.
Works closely with BlueCard claims operations and finance for invoice submissions and appeals.
Research and respond to internal questions relating to claim overpayments and refund activity.
Documents recovery procedures.
Completes special projects, assists with audit requests.