Claims Recovery Specialist

2 weeks ago

Anaheim, California, United States Anaheim Admin Full time

Anaheim Admin is seeking a full-time Claims Recovery Specialist.

The Claims Recovery Specialist is responsible for identifying, collecting, and analyzing underpaid claims by conducting audits on payor performance and reviewing actual payments to ensure adherence to contractual agreements. This role is vital for operational efficiency and requires a keen attention to detail. The specialist will assist the Revenue Cycle Management (RCM) team with training initiatives and follow up on escalated claims.

This position involves a thorough examination of payment variances and the management of denied or rejected insurance claims, focusing on high-volume facilities and complex claim scenarios.

At Anaheim Admin, we recognize the significance of a comprehensive benefits program and are committed to offering unique benefits tailored to the needs of our employees and their families. Our benefits package includes:

  • A competitive benefits package featuring medical, dental, and vision coverage for employees and eligible dependents, life insurance, and long-term disability.
  • Benefits coverage commences after one full month of employment.
  • Generous vacation, sick leave, and holiday benefits.
  • Attractive 401(k) matching contributions and additional perks.
  • For a detailed overview of our benefits, please visit our career site.
Key Responsibilities

The essential functions of this role include:

  • Exercising independent judgment to ensure timely review and auditing of underpaid claims.
  • Analyzing and resolving discrepancies in claims payments to ensure compliance with contractual terms.
  • Compiling necessary documentation to create training materials.
  • Coordinating with relevant parties to implement corrective actions, including pursuing underpayments and addressing billing issues.
  • Drafting appeal letters and communicating contract provisions to third-party payor representatives.
  • Identifying payor trends while maintaining productivity and accuracy in a challenging environment.
  • Developing dashboards and reports on key performance indicators to support management objectives.
  • Extracting and reconciling large data sets from various systems.
  • Reviewing data to identify operational impacts and areas for improvement.
  • Following up on claim submissions to assess acceptance, rejection, or denial status.
  • Researching and appealing denied claims while corresponding with insurance companies to resolve issues.
  • Maintaining a collections rate for assigned payors at or above 70% of allowed charges.
  • Communicating updates and requirements from payors to RCM leadership.
  • Organizing and filing paperwork from health plans and payment correspondence.
  • Updating relevant departments quarterly and reporting issues to management.
  • Supporting the team in providing necessary information for payment recovery within required timeframes.

Non-Essential Functions:

  • Other duties as assigned.

Core Competencies:

  • Welcoming: Prioritizes customer satisfaction and service, handling issues efficiently while maintaining a positive demeanor.
  • Equitable: Promotes inclusive behavior and values diversity within the organization.
  • Confidential: Respects and maintains confidentiality of sensitive information.
  • Accessible: Approachable and open-minded, demonstrating good listening skills.
  • Respectful: Treats everyone with dignity and courtesy.
  • Empathetic: Shows understanding and patience towards others' feelings and perspectives.
Qualifications

Licensure and/or Certification Requirements:

  • Coding certification is advantageous.

Minimum Education:

  • Associate's Degree in a related field is required.
  • Bachelor's Degree or equivalent experience is preferred.

Minimum Work Experience:

  • At least 5 years of experience in medical billing or claims follow-up in an outpatient setting.
  • Advanced knowledge of medical terminology and industry standards.
  • Experience with insurance billing, coding, and reimbursement procedures.
  • Familiarity with HIPAA transaction standards.

Other Requirements:

  • Strong communication skills with payors and insurance companies.
  • Expertise in health care reimbursement and contracting.
  • Ability to maintain confidentiality and demonstrate accuracy in work.
  • Flexibility to work varied hours as needed.

Agency Standard Requirements:

  • Commitment to quality healthcare and customer service.
  • Ability to thrive in a fast-paced environment with changing priorities.
  • Proficiency in Microsoft Office applications and electronic medical records.

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