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Recovery Services Specialist II

Job Category:  Claims
Department:  Claims Integrity
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8033

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Recovery Services Specialist II will work under the claims recovery framework and report to the Claims Recovery Finance Manager. This position will post incoming solicited & unsolicited refund checks received from the providers after auditing claims to ensure recovery is warranted. This position will execute the activities of the claims recovery unit to ensure that L.A. Care remains fully compliant with all Federal, State and regulatory requirements pertaining to claims payment and recovery functions. This position will identify opportunities for recoveries and where the recovery is a result of system misconfiguration. This position will work with the Senior Recovery Specialist and the Claims Validation Analysts to ensure that correct configuration of the system is achieved. 

 

This position will analyze and perform recovery functions to ensure accurate application of reimbursement policies and contractual requirements including: Stop Loss, Retro Terminations and TPL (Third Party Liability). This position recognize and research problems associated with Facility and Provider billing errors, errors associated with L.A. Care payment practices. 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 handle escalated recovery calls received from other teams. This position will maintain an up-to-date 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. and related contractual scenarios.

Duties

Receive and post incoming solicited & unsolicited refund checks received from the providers after auditing claims to ensure recovery is warranted. Prepare overpayment notification and supporting documentation to providers. (20%)

 

Perform the activities of the claims recovery unit to ensure that L.A. Care remains fully compliant with all Federal, State and regulatory requirements pertaining to claims payment and recovery functions. (20%)

 

Analyze claims overpayments and identify opportunities for recoveries and where the recovery is a result of system configuration; and, determine collection recovery strategies. Collect all refunds and recoveries due to LA Care from claim overpayments or payments made in error. Resolve and collect on outstanding refund requests from provider's. Track all recoveries.  (20%)

 

Analyze and perform recovery functions to ensure accurate application of reimbursement policies and contractual requirements including: Stop Loss, Retro Terminations and TPL (Third Party Liability). Recognize and research problems associated Facility and Provider billing errors. Recognize and research errors associated with L.A. Care payment practices.  (20%)

 

Handle escalated recovery calls received from other team. (10%)

 

Perform other duties as assigned. (10%)

Education Required

Associate's Degree
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Experience

Required:
At least 0-2 years of experience in a claims role within a managed care environment with a minimum of 2 years demonstrated experience in processing Health Plan claims recoveries. 

 

Must be experienced in working with Hospital and Provider Billing Departments. 

 

Must be 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. 

 

A deep knowledge of claims code sets including but not limited to ICD9, 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.

 

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.  

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

 

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

Job Segment: Claims, Medical Coding, Insurance, Healthcare

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