Claims Recovery Specialist

4 weeks ago

Orange, United States CalOptima Full time

**Claims Recovery Specialist**

**CalOptima**

**CalOptima Health** is seeking a highly motivated an experienced **Claims Recovery Specialist** to join our team. The Claims Recovery Specialist will be responsible for performing recoveries on claims that have been overpaid and must understand and adhere to recovery regulations mandated by CalOptima Health policies, AB1455, Centers for Medicare & Medicaid Services (CMS), Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC) regulations. The incumbent will provide guidance on transactions, inquiries and complaints from internal and external customers related to overpayment issues. The incumbent will monitor and assist with implementing quality improvement activities such as trend reports and work closely with management to identify training opportunities.

**Position Information**:

- Department**:Claims Administration**:

- Salary Grade**:304 - $53,813 - $80,720 ($25.87 - $38.8077)**:

- Work Arrangement**:Full Telework**

**This position is eligible for telework in California.***

**Duties & Responsibilities**:

- 80% - Program Support
- Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Reviews and analyzes system generated reports to determine recovery opportunities.
- Keeps current on CMS, DHCS, DMHC regulations, CalOptima Health policies, contracts and letters of agreement language as it pertains to recovery.
- Communicates with management to create a follow through plan to resolve recovery cases and alerts of issues that impact quality, i.e., incorrect database configurations, etc.
- Assists with implementation and management of any third-party vendor utilized for recovery, pre-payment claims review or subrogation.
- Initiates and expands recovery opportunities through audits, process enhancements, provider calls and system generated reports.
- Analyzes errors that result in recovery of money to determine their root cause and identifies additional recovery opportunities related to the root cause.
- Analyzes previously processed claims data to determine provider dispute resolution required, ensures that correct payments are released and advises recovery unit supervisor if claim resulted in payment error.
- Communicates to providers clearly regarding guidelines and the reason for the refund request.
- Identifies and reports inconsistencies relative to the adjudication of claims for contract compliance. Prepares and communicates issues and resolutions to management.- 15% - Administrative Support
- Assists the team in carrying out department responsibilities and collaborates with others to support short
- and long-term goals/priorities for the department.
- Answers provider questions regarding recovery based upon contractual and/or CalOptima Health agreements, policies and procedures involving using established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation and claims processing guidelines. Compiles monthly reports based on research identifying opportunities for training, desktop revisions, process improvements and outlining monthly recoveries performed.- 5% - Completes other projects and duties as assigned.

**Minimum Qualifications**:

- High School diploma or equivalent required.
- 2 years of experience processing on-line professional, facility claims and Medicare or Medi-Cal claims in a managed care and/or PPO/indemnity environment required.
- 2 years of provider communication experience in relation to recoveries required.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

**Preferred Qualifications**:

- Associate or bachelor's degree in healthcare administration, health services administration, healthcare policy, public policy, business administration or related field.

**Required Licensure / Certifications**:

- N/A

**Knowledge & Abilities**:

- Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events.
- Organize, be analytical, problem-solve and possess project management skills.
- Work in a fast-paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multi-program teams and external committees/coalitions.

**Physical Requirements (With or Without Accommodations)**:

- Ability to visually read information from computer screens, forms and other printed materials and information.
- Ability to speak (enunciate) clearly i

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