Specialist, Claims Recovery-Spokane Office

Molina Healthcare•Spokane, WA

About The Position

The Specialist, Claims Recovery provides support for claims recovery activities by researching claim payment and billing guidelines, audit results, and federal regulations to determine overpayment accuracy and provider compliance. The role collaborates with health plans and vendors to facilitate recovery of outstanding overpayments, monitors claims backlog and workflow, and helps ensure claims are settled promptly and in accordance with cost-control standards. The position prepares provider overpayment notifications and supporting documentation, maintains reports on collections and outstanding or uncollectible claims, researches claims payments, validates overpayments, updates recovery and claims systems, and follows departmental processing procedures. It also responds to provider correspondence, works with finance on refund and reimbursement processing, supports claims-efficiency initiatives, meets quality and production standards, and completes basic claims projects as assigned.

Requirements

At least 1 year of experience in a clerical role in claims and/or customer service, preferably in managed care, or an equivalent combination of relevant education and experience.
Research and data-entry skills.
Organizational skills and attention to detail.
Time-management skills and ability to manage simultaneous projects and tasks to meet internal deadlines.
Customer service experience.
Effective verbal and written communication skills.
Proficiency with Microsoft Office suite and applicable software programs.

Nice To Haves

Claims recovery experience.
Health insurance experience in a managed care setting.

Responsibilities

Prepare written provider overpayment notifications and provide supporting documentation, including explanations of benefits, claims, and attachments.
Maintain and reconcile department reports for outstanding payments collected, past-due overpayments, uncollectible claims, and autopayment recoveries.
Prepare write-off documents for uncollectible claims and ensure collection efforts have been exhausted before approval.
Research claims payments using billing guidelines, claims policies and procedures, and other resources to validate provider overpayments.
Complete basic validation before offsets, including eligibility, coordination of benefits, standard of care, and diagnosis-related group requests.
Enter and update recovery applications and claims systems for multiple states; prepare accurate overpayment notification letters; and process claims as refunds or auto debits.
Follow departmental policies and procedures for claims processing, recovery, reporting, and documentation.
Respond to provider correspondence about claims recovery requests and provider remittances following recovery.
Collaborate with finance to post provider and vendor refund checks accurately and promptly and to process manual check requests to reimburse providers.
Support initiatives to improve claims department efficiency.
Meet claims department quality and production standards.
Complete basic claims projects as assigned.