Specialist, Claims Recovery (Remote)

Job Summary

Responsible for reviewing Medicaid, Medicare, and Marketplace claims for overpayments; researching claim payment guidelines, billing guidelines, audit results, and federal regulations to determine overpayment accuracy and provider compliance. Interacts with health plans and vendors regarding recovery outstanding overpayments.

Job Duties

Prepares written provider overpayment notification and supporting documentation such as explanation of benefits, claims and attachments.

Maintains and reconciles department reports for outstanding payments collected, past-due overpayments, uncollectible claims, and auto-payment recoveries.

Prepares and provides write-off documents that are deemed uncollectible or collections efforts are exhausted for write off approval.

Researches simple to complex claims payments using tools such as DSHS and Medicare billing guidelines, Molina claims' processing policies and procedures, and other such resources to validate overpayments made to providers.

Completes basic validation prior to offset to include, but not limited to, eligibility, COB, SOC and DRG requests.

Enters and updates recovery in recovery applications and claim systems for multiple states and prepares / creates overpayment notification letters with accuracy. Processes claims as a refund or auto debit in claim systems and in recovery application meeting expected production and quality expectations.

Follows department processing policies and correctness in performing departmental duties, including but not limited to, claim processing (claim reversals and adjustments), claim recovery (refund request letter, refund checks, claim reversals), reporting and documentation of recovery as explained in departmental Standard Operating Procedures.

Responds to provider correspondence related to recovery requests and provider remittances where recovery has occurred.

Works with Finance to complete accurate and timely posting of provider and vendor refund checks and manual check requests to reimburse providers.

Job Qualifications

Required Education : HS Diploma or GED

Required Experience / Knowledge, Skills & Abilities :

1-3 years' experience in claims adjudication, Claims Examiner II, or other relevant work experience

Minimum of 1 year experience in customer service

Minimum of 1 year experience in healthcare insurance environment with Medicaid, or Managed Care

Strong verbal and written communication skills

Proficient with Microsoft Office including Word and Excel

Preferred Education :

Associate's Degree or equivalent combination of education and experience

Preferred Experience :

Recovery experience preferred