This is a fully remote position, open to applicants in United States.

📋 Description

• Identify, assess, validate, and recover overpayments on claims for commercial health insurance providers and state healthcare programs.

• Conduct research on claims, systems, documents, CMS and Medicaid claims-processing policies, client policies, provider and member contracts, and related information.

• Validate claims and algorithms, ensuring no refunds have been issued previously.

• Review and address disputed overpayments from clients and providers.

• Discover new opportunities and trends related to overpayments.

• Analyze data from medical and pharmacy claims, as well as provider and enrollment information, to evaluate trends and opportunities.

• Assist management by providing concept approval information.

• Complete detailed instructions for algorithms transitioned to production.

• Offer feedback regarding inventory levels, algorithm performance, productivity, and emerging trends.

• Work collaboratively with management to identify opportunities for improvement.

• Escalate issues that could negatively affect business relationships.

• Train and support new analysts.

• Participate in the Quality Review process.

• Address day-to-day challenges promptly and effectively.

⛳️ Requirements

• Bachelor’s degree in accounting, business, healthcare, or a related discipline.

• Relevant work experience in a similar role can be considered in lieu of educational qualifications.

• Proven experience in identifying, auditing, and recovering claim overpayments.

• Strong comprehension of calculations and medical terminology.

• Proficient computer skills, particularly in Excel.

• Excellent analytical and problem-solving abilities.

• Strong communication and interpersonal skills.

• Ability to establish and nurture relationships with providers, management, and colleagues.

• Proactive, self-sufficient, and results-driven.

• Customer-focused and team-oriented.

• Willingness to fulfill compliance requirements, including background checks, drug screenings, and disclosures of personal health information or personally identifiable information.