Revenue Recovery Specialist - 26-122

PriMed Management Consulting•San Ramon, CA

About The Position

The Revenue Recovery Specialist maximizes health plan reimbursement through contractual recovery programs, including eligibility guarantees, insured services, drug reimbursement, and Medi-Cal maternity payments. The role reviews, researches, analyzes, submits, reconciles, and follows up on claims, payments, refunds, denials, and unapplied funds, ensuring timely and accurate processing according to health plan policies and contractual requirements. It also audits eligibility and capitation, coordinates system and data corrections, and works with health plans, providers, and internal teams to resolve discrepancies and improve recovery processes.

Requirements

Minimum of 1–3 years of related managed care experience.
Strong knowledge of medical terminology.
Working knowledge of CPT/HCPCS, ICD-10, and NDC codes.
Data-entry, word-processing, and personal computer experience.
Strong verbal communication, decision-making, and problem-solving skills.
Strong organizational skills and attention to detail.
Ability to work independently and cooperatively as a team member.
Excellent customer service skills.
Ability to multitask and work in a productivity-based environment.
Proficiency with a claims payment system and a strong understanding of benefit structures.
Strong knowledge of HPMG rules and guidelines, coordination of benefits (COB), authorizations, health plan DFRs, and UB and HCFA formats.
Knowledge of PHI and HIPAA regulations.
Familiarity with DMHC, Medi-Cal, coordination of benefits, and CMS regulatory requirements.

Nice To Haves

College degree or equivalent preferred.

Responsibilities

Review, research, and analyze claims for Health Plan Recovery Programs, including eligibility guarantees, drug reimbursement, insured services, and Medi-Cal maternity reimbursement.
Submit claim files or notifications according to each health plan’s policies and formats, maintaining HIPAA compliance.
Conduct quarterly eligibility audits related to capitation payments; research enrollment and capitation data and health plan portals, and coordinate eligibility updates with Enrollment staff in QNXT.
Create and process provider recovery requests for payments made in error.
Apply claims-processing, benefit, HPMG guideline, DFR, contract, and regulatory knowledge to ensure accurate and timely submissions.
Use health plan provider portals to access benefit, eligibility, and reimbursement details and reconcile payments.
Post and reconcile Recovery Program payments in the BILL application.
Review denials and non-payments, and submit appeals, disputes, or rebuttals within health plan processes and timeframes.
Identify system, script, contract-language, or DFR issues and work with management, health plans, and Contracting staff to resolve them.
Review EOBs, hard-copy checks, and 835 files for refunds and unapplied funds; process and post solicited and unsolicited overpayments and unapplied funds in BILL.
Research the causes of overpayments and unapplied funds and coordinate resolution of system or script issues.
Identify provider billing patterns, claims-processing errors, and system issues that may cause inaccurate adjudication, capitation deductions, appeals, or untimely or erroneous recovery submissions.
Submit Guideline Discrepancies to Management and the Contracting Department for confirmation or correction.
Participate in workgroups relating to Recovery Programs, auditing functions, encounters, enrollment, and new health plan or recovery program implementations.
Coordinate with health plans, providers, and internal and external departments to support Recovery Programs.
Request internal research of claims-system data discrepancies, including eligibility and benefit plans.
Analyze health plan and clearinghouse claim reports to verify appropriate data is returned within compliant timeframes.
Communicate system and data inconsistencies and recommendations for improvement to department management.
Create and submit provider refund request letters and invoices.
Print and fax capitation deduction and appeals claim information.
Enter check information, distribute mail and correspondence, and perform filing and other related duties as assigned.