Strategic Healthcare Revenue Recovery Specialist

PriMed Management Consulting Services, Inc.; San Ramon (CA); Sur place; USD 70 000 - 76 000; Plein temps

Résumé du poste

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

Qualifications

• 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.

Responsabilités

• 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

Connaissances

Medical terminology

Data entry

HIPAA compliance

Claims processing

Analytical skills

Communication skills

Formation

College degree or equivalent

Description du poste

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