Recovery Audit Analyst I

Solis Health Plans

About The Position

The Recovery Audit Analyst I is responsible for tracking and processing claim overpayments. This role supports the financial integrity of the organization by ensuring accurate application of claim offsets, posting of provider refunds, and reconciliation of recovered funds. The analyst manages voluntary and involuntary recovery activities, monitors demand letters, and collaborates with internal finance teams and external recovery vendors to ensure timely and accurate recovery of overpaid claim dollars in accordance with contractual, regulatory, and CMS requirements.

Requirements

High School Diploma or GED required.
Minimum of 2–4 years of experience in healthcare claims, recovery, billing, finance, or managed care operations.
Experience with claims processing systems and financial reconciliation activities.
Understanding of healthcare claims payment and adjustment processes.
Strong analytical and reconciliation skills
High attention to detail and financial accuracy
Ability to manage multiple recovery cases simultaneously
Strong documentation and reporting skills
Effective communication and collaboration abilities
Problem-solving skills with a focus on root cause identification
Ability to work independently in a production-driven environment

Nice To Haves

Experience in a managed care or Medicare Advantage environment.
Familiarity with recovery audit processes, overpayment identification, or payment integrity operations.
Knowledge of provider refund processing and claims offset methodologies.
Experience working with external recovery vendors or audit firms.

Responsibilities

Apply claim offsets and adjustments related to identified overpayments across multiple lines of business.
Post provider refund checks and electronic payments to corresponding claims accurately and timely.
Process voluntary refunds received from providers, ensuring proper allocation and reconciliation to impacted claims.
Review, track, and manage recovery demand letters issued to providers regarding identified overpayments.
Responds to provider overpayment disputes.
Identify, validate, and document overpayment recoveries in accordance with internal policies and contractual requirements.
Reconcile recovered amounts against claims system data to ensure accuracy in financial reporting.
Monitor outstanding recoveries and follow up on unpaid or partially paid recovery requests.
Ensure proper classification of recovered, canceled, and outstanding overpayment amounts.
Work collaboratively with external recovery vendors to support identification and recovery of overpaid claims.
Review vendor-generated recovery findings for accuracy and compliance with health plan policies.
Track recovery outcomes and ensure vendor performance aligns with contractual expectations.
Communicate effectively with vendors to resolve discrepancies or missing documentation.
Prepare and submit reports to Finance detailing:
Identified overpayments
Cancelled recovery cases
Successfully recovered funds
Outstanding recovery balances
Support monthly, quarterly, and annual financial reconciliation activities.
Assist in audit preparation by providing detailed recovery documentation and supporting evidence.
Accurately update claims systems to reflect recovery activity, including offsets, refunds, and adjustments.
Maintain detailed records of recovery actions, correspondence, and financial transactions.
Ensure consistency between claims, recovery systems, and financial reporting tools.
Research claims history to validate recovery accuracy and resolve discrepancies.
Ensure all recovery activities comply with CMS guidelines, contractual obligations, and internal policies.
Maintain adherence to HIPAA and information security standards when handling member and provider data.
Support audit readiness by maintaining accurate and complete recovery documentation.
Escalate potential compliance or financial risks to appropriate leadership.
Collaborate with Claims Operations, Finance, Provider Relations, and Compliance teams to resolve recovery issues.
Communicate professionally with providers regarding refund requests and recovery determinations when required.
Support internal stakeholders with recovery-related inquiries and reporting needs.
Participate in cross-functional initiatives to improve recovery processes and reduce overpayment occurrence.