Responsible for verifying potential overpaid medical claims for all lines of business and performing a recovery adjustment as appropriate. Compared to the senior role, this position will process a lesser volume of complex claims but will still be held accountable for productivity and quality standards.
2035 -Ops- Payment Integrity
Supv. Cost Containment
- Handles claims training and performs complex assignments independently.
- Process overpayment adjustments for all medical claim types and all lines of business.
- Responsibilities include the ability to independently interpret contracts, verify fee schedules, use CMS and HSS pricing tools.
- Assist with researching and following-up on recovery issues and escalated requests.
- While processing unsolicited refunds, identify systemic set-up issues or manual adjudication patterns for potential quality improvement and greater overpayment recovery opportunities.
- Performs special duties or tasks within scope of the CCU.
High School diploma or equivalent
Experience: Requires 1 year of facility and professional claims processing experience in a healthcare organization. Internal candidates must also meet key performance metrics.
Familiar with PC software including Outlook, Word and Excel