Revenue Recovery Specialist - 26-122

PriMed Management Consulting Services, Inc.; San Ramon (CA); Vor Ort; USD 70.000 - 76.000; Vollzeit

Zusammenfassung

PriMed Management Consulting Services, Inc. in California seeks a Health Plan Recovery Programs specialist to maximize reimbursements and ensure timely submissions under HIPAA.

You will review and submit recovery requests, audit eligibility, analyze claims data, and collaborate with health plans, enrollment, and accounting staff to resolve issues and post payments accurately. This role requires 1–3 years of managed care experience, strong knowledge of CPT/HCPCS, ICD-10 and NDC codes, and

Qualifikationen

• Minimum of 1-3 years of related managed care experience required.
• Strong knowledge of medical terminology
• Working knowledge of CPT/HCPCS, ICD-10 and NDC codes
• Data entry/word processing experience/PC experience
• Strong verbal communication, decision-making and problem solving skills
• Strong organizational skills and detail oriented
• Ability to work independently and as a cooperative member of a team
• Excellent customer service skills
• Able to multi-task and work in a productivity-based environment
• Proficient in the use of a claims payment system with a strong understanding of benefit structure.
• Strong knowledge of HPMG rules & Guidelines, COB, Authorizations, Health Plan DFRs, as well as UB and HCFA formats.
• Knowledge of PHI and HIPAA Regulations
• Familiarity with DMHC, Medi-Cal, Coordination of Benefits and CMS regulatory requirements.

Aufgaben

• Review, research, and analyze claims pulled for submission to each Health Plan for HPMG Recovery Programs.
• Submit files or notifications per Plan policy while maintaining HIPAA compliance.
• Audit eligibility on a quarterly basis related to capitation payments.
• Pull reports and research using enrollment data, capitation data, and plan portals.
• Update eligibility in the QNXT system with Enrollment staff.
• Create and process recovery requests to providers paid in error.
• Apply strong claims processing knowledge to ensure timely and accurate submissions.
• Use health plan portals to access benefit, eligibility, and reimbursement details.
• Post and reconcile payments in the BILL application with Recovery team.
• Review denials or non-payments and submit appeals per plan timelines.
• Identify system/contract issues and coordinate with management to resolve.
• Review EOBs, checks, and 835 files for refunds and unapplied funds.
• Process and post overpayments/unapplied funds in BILL.
• Research root causes of overpayments and coordinate with staff to resolve.
• Identify provider billing patterns and system issues causing mispayments.
• Submit guideline discrepancies to Management and Contracting.
• Participate in workgroups related to Recovery Programs and new implementations.
• Interact with health plans, providers, and internal/external departments.
• Create and submit data discrepancy research requests for QNXT.
• Analyze health plan and clearinghouse reports to ensure timely data.
• Communicate system/data issues and improvement recommendations to management.
• Create Provider Refund Letters and Invoices; print and fax cap deduction and appeal details.
• Data entry of check information; mail/correspondence distribution.
• Miscellaneous duties as assigned

Kenntnisse

Medical terminology

Data entry

HIPAA compliance

Claims processing

Analytical skills

Communication skills

Ausbildung

College degree or equivalent

Jobbeschreibung

We’re delighted you’re considering joining us! At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

Join Our Team! Hill Physicians has much to offer prospective employees. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement: At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are. We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description

Maximize Health Plan reimbursement related to various contractual Recovery Programs in an efficient and timely manner. Identify, analyze, submit, review and recover funds associated with eligibility guarantees, insured services and drug reimbursement. Track and reconcile all claims payment/reimbursement/refund data within the BILL application. Ensure scripts and reports are accurate in preparation for submissions, follow-up and data collection. Understand contractual agreements and DFRs in order to efficiently submit rebuttals, disputes or appeals for denied/unpaid claims. Be able to perform eligibility versus capitation audits and work with various internal and external staff to make necessary updates and request refunds. Monitor Medi-Cal maternity payments and ensure HPMG receives reimbursement timely and according to contractual obligations. Work with Financial Analysis and Accounting staff when they receive Recovery Program capitation reimbursements or deductions, and be able to explain and provide details as needed.

Job Responsibilities

• Review, research, and analyze claims that are pulled for submission to each Health Plan as related to HPMG Recovery Programs (eligibility guarantee, drug reimbursement, insured services, Medi-Cal maternity kicker reimbursement).
• Once research and analysis is complete, submit files or notifications according to each Plan’s policy and format, maintaining HIPAA compliance and following health plan submission processes.
• Audit eligibility on a quarterly basis as related to capitation payments to identify members who are in the system as eligible, but for whom capitation has not been received.
• Pull reports and complete research utilizing enrollment data, capitation data, and health plan website/provider portal information.
• Work with Enrollment staff to update eligibility within the claims processing system (QNXT).
• Create and process recovery requests to providers who were paid in error.
• Utilize strong claims processing and plan benefit knowledge, understanding of HPMG Guidelines, DFR and health plan contract interpretations, DMHC, Medi-Cal and CMS regulatory requirements to ensure claims are pulled, submitted timely and accurately, and according to contractual agreements.
• Also utilize health plan secure provider portals to access benefit, eligibility, and reimbursement details as necessary to properly reconcile payments.
• Work with Recovery team members to post and reconcile payments in the BILL application.
• Review denials or non-payments, and submit appeals/disputes or rebuttals according to each health plan’s submission process and timeframes.
• Identify system/script or contract language/DFR issues and work with manager, health plan and internal Contracting staff to resolve issues.
• Review and research EOBs, hard copy checks, and 835 files for refunds and unapplied funds (payments received for claims that were not paid by HPMG or not submitted to plan for reimbursement).
• Process and post payments for unsolicited and solicited overpayments/unapplied funds in the BILL application.
• Research root cause of overpayment or unapplied funds and work with manager, health plan, and other internal staff as necessary to resolve system/script.
• Identify provider billing patterns, processing errors, and/or system issues that cause inaccurate adjudication of claims causing potential capitation deducts/appeals or that result in untimely or erroneous recovery program submissions.
• Submit Guideline Discrepancies to Management and the Contracting Department for confirmation and/or correction.
• Participate in workgroups as related to Recovery Programs or auditing functions including encounters and enrollment, and new health plan/recovery program implementations.
• Interact with health plans, and providers as well as internal and external departments to ensure success of Health Plan Recovery Programs.
• Create and submit requests to internal departments to research data discrepancies in the claims system (QNXT), i.e. eligibility & benefit plans.
• Analyze health plan and clearing house claim reports to ensure appropriate data is returned within compliant time frames.
• Communicate system and data inconsistencies as well as recommendations for improvement to department management.
• Create Provider Refund Request Letters and Invoices Print and fax Cap Deduct & Appeals claim information Data entry of check information Mail/Correspondence Distribution Miscellaneous Filing Other related duties as assigned

Required Experience

• Minimum of 1-3 years of related managed care experience required
• Strong knowledge of medical terminology
• Working knowledge of CPT/HCPCS, ICD-10 and NDC codes
• Data entry/word processing experience/PC experience
• Strong verbal communication, decision-making and problem solving skills
• Strong organizational skills and detail oriented
• Ability to work independently and as a cooperative member of a team
• Excellent customer service skills
• Able to multi-task and work in a productivity-based environment
• Proficient in the use of a claims payment system with a strong understanding of benefit structure.
• Strong knowledge of HPMG rules & Guidelines, COB, Authorizations, Health Plan DFRs, as well as UB and HCFA formats.
• Knowledge of PHI and HIPAA Regulations
• Familiarity with DMHC, Medi-Cal, Coordination of Benefits and CMS regulatory requirements.

Required Education

Minimum level of education required: college degree or equivalent preferred.

Additional Information

Salary: $70,000 - $76,000 Annual Hill Physicians is an Equal Opportunity Employer PriMed Management Consulting Services, Inc., is the management services organization for Hill Physicians Medical Group, the largest Independent Physician Association (IPA) in Northern California. More than just a job - We’re making a meaningful contribution to healthcare. Everyone at PriMed contributes to making quality healthcare accessible for Northern Californians. We have a unique collection of skilled professionals that work well together and have been recognized as one of the top places to work and one of the healthiest places to work in the Bay area.