Claims Cost Containment & Recovery Specialist

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 45,000 - 65,000; Full time

Job summary

CommunityCare HMO Inc. in Tulsa, OK is seeking a Cost Containment Specialist to ensure appropriate reimbursement on claims and manage overpayments. You will identify refunds, coordinate COB, review transplant and reinsurer processes, and generate recovery reports.

The role requires strong attention to detail, effective communication, and the ability to work with diverse teams. This full-time position offers growth within a healthcare cost containment function.

Qualifications

• Self-motivated and able to work with minimal direction.
• Ability to read and understand claims processing manuals and CPT codes.
• Knowledge of claims processing manuals and health benefit booklets.
• Knowledge in contracted managed care plan terms and rates for multiple lines of business.
• Proficient in Microsoft applications.
• Ability to perform complex mathematical calculations.
• Demonstrated learning agility
• Highly attentive to detail.
• Ability to work with a variety of individuals at all levels within and outside the company.
• Successful completion of Health Care Sanctions background check.
• Possess strong oral and written communication skills.
• Ability to organize time effectively and set priorities to meet deadlines.

Responsibilities

• Generate and update database of all applicable claims which have refunds due.
• Run daily reports for future provider payable amounts by line of business.
• Access claims and recoup the proper dollar amount.
• Keep track of claims that cause negative balances and correct them as needed.
• Enter claim remarks of all recovery attempts and activities.
• Communicates with providers regarding outstanding overpayment amounts and keep phone log records of accounts.
• Reply to calls and emails in a timely manner.
• Update recoupment workflow of changes.
• Generate reports of recouped dollars by line of business as well as reporting bad debt amounts.
• Review and advise examiners on processing of transplant and Centers of Excellence claims.
• Monitor, log and track members cases for reinsurance purposes.
• Report monthly to finance and self-funded groups status of all active reinsurance members.
• Ensure correct application of coordination of benefits for our member population.
• Attempt subrogation for claims related to third party liability.
• Assist in the negotiation of settlements related to third party liability claims.
• Contribute to the creation of a pleasant working environment with peers and other departments.
• Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Generate reports and tracking of requests, receivables, savings and volumes.
• Interface with various departments regarding cost containment actions.
• Assists in researching and solving complex problems related to claim payments.
• Perform other job-related duties as assigned.

Skills

Self-motivation

Microsoft Office

Communication skills

Attention to detail

Time management

Independent work

Education

High school diploma or equivalent

Tools

Microsoft Office Suite

Job description

CommunityCare HMO Inc. in Tulsa, OK is seeking a Cost Containment Specialist to ensure appropriate reimbursement on claims and manage overpayments. You will identify refunds, coordinate COB, review transplant and reinsurer processes, and generate recovery reports.

The role requires strong attention to detail, effective communication, and the ability to work with diverse teams. This full-time position offers growth within a healthcare cost containment function.