Claims Recovery Specialist I (Remote)

CareFirst BlueCross BlueShield; Charleston (WV); On-site; USD 36,000 - 65,000; Full time

Job summary

CareFirst BlueCross BlueShield seeks a Claims Recovery Specialist I to review and audit medical and dental claims, manage active overpayments, and maximize recovery amounts. The role collaborates with claims, service, financial, and vendor auditing teams to complete adjustments and ensure compliance with applicable mandates.

Under supervision, you will communicate with members, providers, and carriers to recover balances, negotiate repayment terms when necessary, and support overall refunds and

Qualifications

• Education: High School Diploma or GED.
• Experience: 3 years claims processing.
• Preferred: claims adjustment experience.

Responsibilities

• Review and audit medical and/or dental claims to recover overpayments, ensuring proper documentation. Initiates recovery efforts for members/providers. Includes negotiating repayment when needed.
• Communicates with carriers, members, and providers to recover and settle unpaid claims and respond to inquiries about overpayment balances.
• Participate in internal/external audit and recoupment meetings and pursue ongoing knowledge through training.

Skills

Math aptitude

Communication

Client interaction

Deadline oriented

Education

High School Diploma or GED

Job description

Resp & Qualifications

Under direct supervision, the Claims Recovery Specialist I review and audits medical and/or dental claims to recover payments. They will provide day-to-day management of active overpayment recoveries. Specialist will work to maximize recovery amounts due to refund of payments made in error to members, providers, retro terms, and/or focused provider audits. This position will work closely with the claims, service, financial, and vendor auditing departments to complete claims adjustments.

Purpose

Under direct supervision, the Claims Recovery Specialist I review and audits medical and/or dental claims to recover payments. They will provide day-to-day management of active overpayment recoveries. Specialist will work to maximize recovery amounts due to refund of payments made in error to members, providers, retro terms, and/or focused provider audits. This position will work closely with the claims, service, financial, and vendor auditing departments to complete claims adjustments.

Essential Functions

• Under direct supervision, review and audits medical and/or dental claims to recover overpayments, ensuring all parts of the process are documented properly. Initiates recovery efforts for members and/or providers consistent with local and federal mandates. Distributes written correspondence to members and/or providers in order to recoup overpaid claims, negotiate repayment agreements when necessary, and ultimately reduce the company's care line.
• Communicates, via phone, email, and correspondence, with carriers, members and/or providers to recover and settle unpaid claims. Responds to carrier, member, provider, and/or customer service inquiries regarding outstanding claims and/or overpayment balances. Investigates and performs Investigates and performs adjustments to claims to reflect cash returned by members and/or providers in order to reduce and accurately reconcile customer accounts.
• Participate in all internal/external meetings relating to Audit and Recoupment. Improves claims audit and recoupment job knowledge by attending training sessions.

Qualifications

Education Level: High School Diploma or GED.

Experience: 3 years claims processing.

Preferred Qualifications

• Claims adjustment experience.

Knowledge, Skills And Abilities (KSAs)

• Mathematical ability/aptitude.
• Communication skills.
• Ability to deal with both internal and external clients.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range:

$35,712 - $65,472

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location.

• In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

Physical Demands

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship