Cost Avoidance Specialist I

Responsibilities

• Assess, implement, and monitor activities related to recoveries and cost savings of medical claims.
• Perform assessments and identify potential overpayments on claims related to all lines of business.
• Research and identify overpayments related to over utilization of procedures, billing procedures, potential fraudulent claims, duplicate payments, and overpayments due to lack of coordination of benefits with member's primary health care insurance policy such as a private health insurance, Medicare coverage, or an open case with CCS.
• Perform recovery activities associated with claim audit findings.
• Report dollar amounts identified for recovery, recovery amounts received, and reasons for overpayments.
• Identify via reports, Medi-Cal overpayments due to retro-active Medicare or Third Party coverage and the recoupment of same.
• Research and process all Partnership product lines for COB and Third Party Liability (TPL) recoveries and communicate outcome with Cost Avoidance Supervisor.
• Prepare reports as per requirements of Department of Health Care Services (DHCS) and other regulatory or auditing agencies for Cost Avoidance Supervisor review.
• Assist with research, analysis and reports of claims as requested by management.
• Researches and validates all provider refund checks received.
• Identifies if refund check received is due to Partnership, reason for the refund; Identifies configuration or training issues related to the payment received; Recommends appropriate actions, statistical or regular adjustment, completes adjustments and reports outcome to Cost Avoidance Supervisor.
• Researches and validates other health insurance coverage of Partnership members.
• Reviews claims routes and identifies other insurance via attachments provided.
• Utilizes call center, TransUnion or DHCS website to validate the active status and type of insurance.
• Updates Amisys appropriately based upon the type, coverage dates and scope of coverage.
• Prepares reports and notification to providers of potential recovery if the insurance is found to be retroactive.

Qualifications

• High School Diploma or equivalent and minimum two (2) years’ experience in health care including experience in processing claim in an automated claims environment, working knowledge of medical terminology, and related procedure and diagnostic coding (CPT-4, ICD-9, ICD-10, HCPCS); or equivalent combination of education and experience.
• Experience in Medi-Cal operations, Amysis, COB, Reinsurance, and claims billing procedures preferred.