Claims Recovery Specialist II (Remote)

PURPOSE

The Claims Recovery Specialist II reviews and audits medical and/or dental claims to recover payments.

Essential Functions

• Reviews, audits, and/or initiates recovery efforts for medical, and/or dental claims to recover overpayments, ensuring all parts of the process are documented properly.
• Contacts carriers, members and/or providers, via phone, email, and correspondence, to recover and settle overpaid and/or unpaid claims.
• Responds to carrier, customer and/or provider service inquiries regarding outstanding claims and/or overpayment balances.
• Proactively identifies needs and responds appropriately through investigating, problem solving, engagement of other internal or external resources, and providing high level service.
• Adjusts claims to reflect cash returned by members and/or providers to reduce and accurately reconcile customer accounts.
• Distributes written correspondence to policy holders to recoup overpaid claims, negotiate repayment agreements when necessary, and ultimately reduce the company's care line.
• Participate in all internal/external meetings relating to Audit and Recoupment.
• Improves claims audit and recoupment job knowledge by attending training sessions.
• Participates with department management in revising Audit and Recoupment SOPs.

Qualifications

• Education Level: High School Diploma or GED.
• Experience: 5 years claims processing.
• Preferred Qualifications: 1 year adjustment processing.

Knowledge, Skills And Abilities (KSAs)

• Mental ability/aptitude.
• Communication skills.
• Ability to deal with both internal and external clients.

Salary Range

$42,624 - $78,144

Equal Employment Opportunity

CareFirst is an Equal Opportunity employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Physical Demands

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.