Recovery Services Processor II

Job Summary

The Payment Integrity (PI) Recovery Services Processor II will work under the Payment Integrity recovery services framework. The PI Recovery Services Processor II will review, post, and reconcile incoming solicited and unsolicited refund checks to the appropriate claims processing platform while maintaining performance metrics. The PI Recovery Services Processor II will review and retract claims in appropriate claims processing platform to withhold recovery amounts against future provider payments while maintaining performance metrics. The PI Recovery Services Processor II will execute the activities of the recovery services unit to ensure that L.A. Care remains fully compliant with all Federal, State and regulatory requirements pertaining to claims payment and recovery functions.

The PI Recovery Services Processor II will identify incremental recovery opportunities by actively processing  refunds and retractions to recognize trends resulting from provider billing issues or system misconfiguration. This position conduct in depth research to ensure recovery (retraction) functions are accurately applied according to reimbursement policies and contractual requirements. This position will consistently evaluate applicable policies and procedures and recommend changes, as appropriate, to ensure efficient and accurate processing of claims within L.A. Care’s claims department. This position will maintain current and historical knowledge of national and state-wide standards pertaining to claims processes and recoveries and will ensure that these requirements are implemented throughout the recovery unit.

Duties

Review, post, and reconcile incoming solicited & unsolicited refund checks to the appropriate claims processing platform. Review and retract claims in the appropriate claims processing platform to withhold recovery amounts against future provider payments. (20%)

Assist Recovery Services Supervisor with in depth research of inquiries submitted from internal and external departments. Provide assistance/guidance with complex audits to Processor I staff members. (20%)

Recommend new pipeline opportunities based on active analysis of refunds received. Assist with Quality Assurance (QA) of new business processes with internal departments and vendors. Assist Recovery Services Supervisor in monitoring work queue inventory and prioritization based on departmental needs. (20%)

Prioritize work to achieve performance metrics while managing multiple competing priorities and tasks.  Identify and document business processes for the recovery services team.(20%)

Handle and remediate escalated recovery communications (email, calls, etc.). Facilitate training sessions with Processor I staff on complex audits. Auditing of Refunds and Retractions in Centralized Overpayment Repository and Core Platform(s).  (10%)

Perform other duties as assigned. (10%)

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 6months-1 years of experience in a claims role within a managed care environment processing Health Plan claims recoveries or demonstrated proficiency in current recovery role while exceeding performance metrics. 

Preferred:
At least 3 years demonstrated experience in processing Health Plan claims recoveries or demonstrated proficiency in current recovery role while exceeding performance metrics. 

Experienced in working with Hospital and Provider Billing Departments. 

Experienced in interpreting complex contractual terms with Providers, Facilities, Plan Partners, delegated groups.
 

Skills

Required:
Solid understanding of standard claims processing systems and claims data analysis. 

Working knowledge of claims coding and medical terminology. 

Ability to effectively prioritize and meet deadlines while managing multiple competing tasks. 

Must have excellent communication skills, strong analytical, team building skills.  

Ability to work effectively with diverse team members.  

Preferred:
A deep knowledge of claims code sets including but not limited to HCPCS, DRG, APC and other inpatient and outpatient coding systems. Knowledge of ICD 10 is desirable. 

Good knowledge of contractual pricing mechanisms for inpatient, outpatient, LTC and ancillary services. 

Must have a solid understanding of the application of Division of Financial Responsibility (DoFR) to claims processing. 

Must be familiar with coordinating benefits between health plan payers.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information