Performs advanced and in-depth data analysis and provider profiling to determine recovery opportunities for claims that are overpaid due to retroactive member termination, inappropriate coding, duplication of payments, non-authorized services, erroneous contract or fee schedule reimbursement, non-covered benefit(s) and other reasons. Provide recommendations to reduce future occurrences of overpayments.
Location: Hoover Blvd, Tampa, FL
Department: Ops-Payment Integrity
Reporting to: Sr Mgr, Recovery
- Analyzes contractual obligations and identifies/pursues overpayments on claims for various reasons.
- Prepares detailed analyses on mis-paid claims with complex business requirements and partners with IT resources for data pulls, analysis, and validation.
- Summarizes information for business partners for review and resolution and provides recommendations on recovery strategies.
- Monitors progress of overpayment projects and executes on next steps.
- Develops comprehensive and detailed analyses on erroneous payments in order to support the revenue collection and reconciliation process.
- Develops simple data queries to generate reports of overpaid claims
- Required A High School or GED
- Preferred A Bachelor's Degree in a related field
- Preferred or equivalent work experience
- Required 3 years of experience in data analysis and business criteria development
- Required 3 years of experience in Claims processing, Claims Operations or Claims recovery
Licenses and Certifications:
- Intermediate Demonstrated analytical skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated problem solving skills
- Intermediate Ability to influence internal and external constituents
A license in one of the following is required:
Technical Skills: Languages: