Location: Woodland Center Blvd/Idlewild Ave, Tampa FL
Department: Ops-Payment Integrity
Reporting to: Mgr, Recovery
Performs 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.
Additional Responsibilities:Candidate Education:
- Acts as team lead on large projects requiring coordination with multiple departments within and outside the company.
- 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.
- Assists in designing and implementing relational data structures related to overpayment issue.
- Summarizes information for business partners for review and resolution and provides recommendations on recovery strategies.
- Monitors progress of overpayment projects and executes on next step
- Develops comprehensive and detailed analyses on erroneous payments in order to support the revenue collection and reconciliation process.
- Develops complex data queries to generate reports of overpaid claims
- Mentors junior recovery analysts
- Ownership and oversight of specific recovery processes
- Required A Bachelor's Degree in in related field
- Required or equivalent work experience
- Required 5 years of experience in Business criteria development
- Required 5 years of experience in Claims processing, Claims Operations or Claims recovery
- Required 1 year of experience in Data Analysis
Licenses and Certifications:
- Advanced Demonstrated analytical skills
- Advanced Demonstrated interpersonal/verbal communication skills
- Advanced Ability to lead/manage others
- Advanced Other Excellent problem analysis skills
- Advanced Other Excellent consultative skills
- Advanced Other Excellent judgment skills
A license in one of the following is required: