To maximize the recovery of revenue available through various resources. This entails identification of areas where tighter monetary controls are needed as well as project work in these areas to recover revenue wherever appropriate and to prevent future overpayments. The Recovery Case Coordinator II will also be expected to perform the general duties of recoveries and assure standard and accurate claim reimbursement practices are in compliance with Health Plan service agreements, NCQA, state and federal agencies. These duties include but are not limited to: The identification of a recovery, calculation of the potential refund, as well as Identification of and coding analysis of billing and coding practices with reporting and education in areas where tighter documentation, coding and their subsequent monetary controls are needed, conduct and review external audits in either a proactive or reactive manner. Provide investigative support in pursuing recovery of inappropriate claims. Formulate audit reports and identifies and documents funds to be recovered and returned to the organization. This position will be responsible for ensuring that both HIPAA and SOX standards are met and adhered to on an ongoing basis. This position reports directly to the Post Adjudication Support Supervisor.
Essential Functions:
- Receives, analyzes, and coordinates recoveries based upon legally defendable, fair and accurate industry standard practices which are in compliance with Health Plan service agreements, NCQA, state and federal regulatory agencies as well as CMS and other coding standards
- Accurately calculate recoveries based on eligibility, appropriate payment methodology, application of contract versus non-contract, KPNW policies and application of state, federal and CMS (Medicare) regulations
- Conducts & coordinates moderately complex retroactive audits and participates in post audit exit interviews with providers and vendors where appropriate to correct discrepancies
- Makes equitable contributions to the recoveries team and shows expertise in a variety of case types
- Work with information available from all sources including technological, to analyze where claims being overpaid or paid unnecessarily
- Research coding & billing overpayments to determine if cause is an isolated event or a system issue and make recommendations to correct system weaknesses
- Identification of new cost containment & retroactive audit recovery areas
- Compile data on potential inadvertent coding & billing errors and subsequent overpayments and assist in developing recovery strategy via retroactive audits
- Ensure adherence of Health Insurance Portability and Accountability Act (HIPAA) and other regulatory guidelines including privacy & security
- Maintains a program for continuing education through attendance in programs affecting the third party payer system and continuously pursues educational opportunities as available. Reviews pertinent articles, regulatory requirements and other documents affecting policies and rights of recovery
- Other duties as assigned
- Assists w/ the maintenance of files relating to external audits and investigations
- Assists w/ formulation of company policies that address loss exposures and solutions
- Maintains a professional working relationship for the detection of local and national fraud and abuse schemes with various associations & agencies
- Research & respond to provider inquiries
- Act as a liaison for Claims Administration to other departments
Qualifications:
Basic Qualifications:
- 3 years healthcare and/or claims experience
- 3 years experience using a PC to include working knowledge of software applications: Microsoft Word and Excel
- Currently certified in one of the following: RHIT, RHIA, or CPC
- Knowledge of claims processes
- Demonstrated experience in analysis of medical records
- Knowledge of ICD9-CM, CPT, and HCPCS coding and medical terminology
- Knowledge of retrospective review philosophy, tools, and methods
- Ability to handle highly confidential information with discretion
- Ability to work well with others in stressful situations
- Demonstrates customer-focused service skills
- Proven ability to think and act independently and as a team player as well as professionally and with attention to detail
- Excellent time management/prioritization skills with demonstrated ability to handle multiple tasks, shifting priorities, and successfully meet deadlines
- Demonstrated excellent oral and written communication skills
- Cognizant of organizational behavior and use of appropriate lines of communication
Preferred Qualifications:
- 5 or more years of progressively responsible medical claims adjudication experience in an HMO, or other insurance setting
- Previous experience in Medical Audit using automated review systems
- Thorough knowledge of CMS guidelines as well as retrospective review philosophy, tools, and methods
- Computer skills to include working knowledge of software applications such as Microsoft Word, Excel and Access, email, and project tracking
- Ability to work with physicians and provider office staff
- Working knowledge of statistical tools and methods
- Demonstrates customer-focused service skills
- Excellent written and verbal communication skills
- Excellent problem-solving, qualitative and analytic skills
- Well-versed in organizational behavior and lines of communication
- Effective time management and organization skills
Salary Range:
$48,460 - $63,940
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.