Claims Audit & Recovery Manager

• Make sure to review daily claims Inquiry.
• Analyze claims payment history and provider contracts to identify and determine where overpayment recoveries exist.
• Conduct root cause analysis on systemic issues; formulate action plan to avoid incorrect payment through review of contracts, Medicare claims payment rules, internal system, and beneficiary impact.
• Documentation of all related recovery efforts in different claims and database systems to document recovery efforts as required by each specific client.
• Perform documentation and coding audits, reviewing medical claims, records, and charges to ensure compliance with CPT coding and ICD10 coding standards.
• Maintain KPI’s daily counts.
• Analyze monthly CMS reports.
• Analyze current payment policies and make recommendations to improve program integrity and organizational processes.
• Oversee all inquiries that come in from either member services or providers with questions, claims statuses, EOP’s.
• Reviewing of itemized bills and reviewing cases with UM team.
• Generate letters to advise if claims on file along with spreadsheet of payments made.
• Review correspondence received from Insurance Companies or Attorney Offices.
• Draft written reports that detail audit findings and recommendations to senior leadership, Department management/personnel, and/or other related business partners.
• Ensure timely and accurate completion of recovery projects and related reporting.
• Establish communication and rapport with clients, members, and providers.
• Research, resolve, and respond to correspondence (both written and verbal) from members, providers, and clients.
• Follow all applicable State and Federal laws related to recovery efforts.
• Timely follow up on all files.
• Performed additional duties as assigned.

Qualifications and Education:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Skills and Ability:

• Knowledge of automated claims processing systems and other complex claim processing rules and regulations.
• Proficient in processing / auditing claims for Medicare plans.
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations.
• Excellent communication, organizational, and interpersonal skills (both written and verbal).
• Ability to work independently while maintaining a relationship and working with other team members.
• Ability to learn and adapt to various claim system platforms and analyze claim payments for validation of potential other payor liability.
• Strong computer skills with experience in Microsoft Word and Excel a plus.
• Thorough knowledge and understanding of medical claims terminology.
• Ability to handle multiple tasks in a fast-paced environment and meet deadlines.
• Proven ability to work under high production and quality standards.
• Proven analytical, collections, and problem-solving skills.
• Position may require flexible hours, and unscheduled overtime.

Education and Experience:

• Bachelor’s degree preferred.
• 2-3 years’ experience in medical claims processing and 1- 2 years’ experience in claims auditing.
• 2 years’ experience in a managed healthcare environment related to claims processing/auditing, including Medicare plans.
• 2 years’ experience with CMS requirements, and other complex claim processing rules and regulations.
• years’ experience using Healthcare Common Procedure Coding Systems (HCPCS), CPT, ICD, Medicare codes. Collections/recovery and/or accounts receivable experience preferred.
• Familiarity with health benefits and provider contract provisions is preferred.
• Self-motivated, goal-oriented individual with the ability to work in a fast-paced and demanding work environment.
  

Mathematical Skills:

• Ability to compute and validate claim payments to calculate recovery amounts.
• Ability to use formulas, and charting features within spreadsheets.

What Set Us Apart:

Join Solis Health Plans as Claims Audit & Recovery Manager become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!