Medical Payment Recovery Coordinator II

Job Summary

This Medical Payment Recovery Coordinator II will be responsible for the monitoring and recovery of various revenue opportunities. This position will work closely with the Claims Department, Member Services Department, Provider Network Operations, Participating Provider Groups, Reinsurance carrier and Centers for Medicare and Medicaid Services(CMS) representatives to ensure regulatory/contractual requirements are implemented. This position will need excellent Data Management skills, computer skills, and organizational skills. Duties will include coordinating with other departments, outside contact with contractual entities, create reports, journal entries and account analysis. This position will report to the Director of the department.

Duties

Responsible for the CMS Plan to Plan reconciliation and attestation process. Review monthly CMS reports provided related to PDE activity. Identify opportunities for recovery of funds for Special Needs Plan (SNP) enrollment which have transferred to/from CMS contracted health plans. (15%)

Responsible for claims refunds processing. Includes preparing refund check for General Accounting, send email with PDF packet to Claims, coordinate processes with claims payable, obtain proper G/L accounts, and enter data accurately and timely into MHC. Ensure appropriate required action is performed and letter, if needed, accurately details action. Follow-up with claims within one week from receipt to MPSS department. Identify claims which have not been collected or reversed within the 30 day regulatory requirement. JE preparation is required and G/L#20705 analysis and reconciliation. (20%)

Responsible for the recovery of stop loss claims. Monitor the monthly reinsurance report for member reaching established thresholds. Monitor reinsurance report for financial activity reaching and surpassing coverage threshold activity. All activity will include detailed line item files produced and sent to the carrier immediately. Coordinate with Claims department to ensure needed documentation is supplied to carrier. Responsibilities include recoveries JE are booked to the G/L and account analysis is completed accurately. (15%)

Responsible for the research, response and, if need, reimbursement of the AB1324 requests. Coordinate with the Capitation Analyst to ensure retro transactions occurred, documentation is complete. Ensure that response is made with in 30 days of request submission. (15%)

Responsible for the Provider Contract Management. Ensure all contracts are files into the e-folder and PIFs are immediately distributed to appropriate analyst. (10%)

Responsible for the weekly preparation of the upload files for the cost of care payments. This includes incentives, refunds and capitation. this process should be coordinated with the Claims payable person. (10%)

Responsible for the daily research and response for positive pay issues. (5%)

Perform other duties as assigned. (10%)

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 0-1 years of accounting related work experience in an HMO office setting or an accounting department.

Preferred:
MHC/QNXT experience.

Skills

Required:
Excellent organizational skills.

Demonstrated ability to work effectively in a team environment.

Excellent verbal and written communication skills.

Excellent computer skills; good knowledge of Microsoft excel and word.

Ability to multitask. 

Solid understanding of accounting terminology.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information