Claims HMO - Cost Containment Specialist 140-1003

About the role

The Cost Containment Specialist ensures CommunityCare receives appropriate reimbursement of payment on claims by identifying and collecting overpayments, handling third-party liability, coordinating benefits, and managing transplant and reinsurance claims.

Responsibilities

• Generate and update a database of claims with refunds due.
• Run daily reports for future provider payable amounts by line of business.
• Access claims and recoup the proper dollar amount; correct claims causing negative balances.
• Enter claim remarks for all recovery attempts and activities.
• Communicate with providers regarding outstanding overpayment amounts and maintain phone log records.
• Respond to calls and emails in a timely manner.
• Update recoupment workflow of changes.
• Generate reports of recouped dollars by line of business and report bad debt amounts.
• Review and advise examiners on processing transplant and Centers of Excellence claims.
• Monitor, log, and track member cases for reinsurance purposes.
• Report monthly to finance and self-funded groups on the status of active reinsurance members.
• Ensure correct application of coordination of benefits for the member population.
• Attempt subrogation for claims related to third-party liability.
• Assist in negotiating settlements related to third-party liability claims.
• Contribute to a pleasant working environment with peers and other departments.
• Adapt to changes in claims processing, benefits, limits, and regulations.
• Generate reports and track requests, receivables, savings, and volumes.
• Interface with various departments regarding cost containment actions.
• Research and solve complex problems related to claim payments.
• Perform other job-related duties as assigned.

Requirements

• Self-motivated with the ability to work with minimal direction.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes, and perform claims processing procedures.
• Knowledge of claims processing manuals and health benefit booklets.
• Understanding of contracted managed care plan terms and rates for multiple lines of business.
• Proficient in Microsoft applications.
• Ability to perform complex mathematical calculations.
• Demonstrated learning agility and high attention to detail.
• Ability to work with individuals at all levels within and outside the company.
• Successful completion of a Health Care Sanctions background check.
• Strong oral and written communication skills.
• Ability to organize time effectively and meet deadlines.

Qualifications

• High school diploma or equivalent required.
• Three years of related work experience in claims processing, data entry, or medical billing.
• One year of claims processing experience within CommunityCare or another healthcare environment preferred.
• One year of collections experience preferred.