Position Summary 

The Claims Recovery & Audit Specialist researches claims payments and pursues recoveries through contact with various parties and/or claim recoupments, as needed. The specialist manages all claims that require recovery for overpaid or incorrectly paid claims, coordination of benefits with other insurance companies, claims paid after termination, claims paid to wrong providers, duplicate payments, subrogation refunds and all other claims scenarios. May include initiating telephone calls to providers and other insurance companies to gather coordination of benefits data. Responsible for sending refund request letters to provider. 

Duties and Responsibilities

· Investigate, resolve, and pursue recoveries on all types of claims. 

· Responsible for update refund check in core claims system 

· Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits information.

· Recover incorrectly processed claims through the claim’s adjustment process. 

· Monitor and stay current with Plans benefits and policy language. 

· Deal with internal/external personnel in an effective professional manner; providing information requested and resolving problems that arise. 

· Able to work in a fast paced, varied environment and manage priorities while maintaining a positive, customer focused attitude. 

· Monitor and report pertinent issues and information to management for awareness, knowledge, and action. 

· Respond accurately, courteously, and quickly to phone and written correspondence related to contract, provider, client and insureds’ inquiries or concerns with appropriate follow up as necessary. 

· Research and respond to audit requests from internal and external auditors and PNS providers quickly and efficiently.

· Evaluate and make recommendations on training material and methodology.

· Support the implementation of new procedures and/or operational changes to support Company vision and strategy. 

· Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance. 

Knowledge

· Bachelor’s degree in accountancy or commerce along with 3+ years of claims auditor experience 

Skills

· Data management ability and knowledge in computer, including MS Excel and MS Words

· Familiar with health insurance concepts, practices, and procedures 

· Knowledge of HCFA 1500 and UB04 billing forms, EOP as well as related data interpretation 

· Solid understanding of different provider payment methodologies