Job Description

Job Description

Job Description

The successful candidate will research and identify complex and high dollar overpayments on previously processed claims for multiple product lines, assist department Leadership in DOFR implementation projects and processes. Review, request, record, and, report on claim refunds and capitation deductions from various IPA’s/ Health Plans accurately utilizing Access, Excel, Word, EZ Cap, and medical claims information. The Recovery Specialist analyzes multiple different data sets to determine whether or not a refund is valid and assists with recovering on any medical claims that have been overpaid or deducted from our Clients in error.

Duties and Responsibilities: 

• Assist in DOFR implantation processes and any other DOFR related task assignments. 
• Review, track, and dispute (as needed) capitation deductions received from various Health Plans. 
• Review retro eligibility term reports monthly and assist with initiating refund requests for claims identified as being overpaid. 
• Run reports for each of our Clients and initiate recoupments/ offsets for claims that qualify.
• Review Provider Dispute Resolution (PDR) forms received from various internal departments and perform thorough research to determine whether an overpayment/ underpayment being contested is valid.
• Cross training to assist on various tasks, as needed, within the department.

Minimum Job Requirements:

• 3 years of experience with medical claims and/ or audits strongly preferred.
• AA degree or equivalent combination of education, training, and experience is required. 
• Experience in claims processing/ collections, Health Plan capitation deductions, and medical terminology strongly preferred. 
• EZ-Cap experience preferred.

Skills and Abilities:

• Demonstrate strong understanding and experience using Excel.
• Competency in MS Office and PC skills required. 
• Demonstrate organizational, interpersonal and communication skills. 
• Ability to perform multiple tasks in a fast pace work environment while maintaining production and quality standards.

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