Recoveries Specialist

Recoveries Specialist
OVERVIEWThe Recoveries Specialist is responsible for maximizing net revenue in the form of reimbursement or refund from another liable party for costs or services which are not the financial responsibility of Mills-Peninsula Medical Group or through shared risk arrangements with the health plans. The Recoveries Specialist reports directly to the Controller.SPECIFIC DUTESHealth Plan Recoveries
Work with IS to develop reporting for bill-backs, specific to each health plan, for carve-out services paid for by MPMG
Bill health plans monthly for servicesDevelop Finance reporting tool, by plan and type of service
Reconcile payments from health plans to ensure timely and accurate payments
Work with Contracts Manager to resolve contract disputes
Develop accrual methodologies for these services
Refunds
Receive and process all refund checks
Maintain database of provider refundsDevelop trends and share with other Departments (Claims, Medical Management, Finance, Member Services)Stoploss
Work with IS to develop stoploss reporting
Compile medical encounter data for stoploss liability on a monthly basis, beginning six months into the contract year
File stoploss claims and submit reports to carriers for reimbursement
Reconcile payments to ensure timely and accurate reimbursement
Shared Risk Reporting
Review detailed health plan shared risk reports on a quarterly basis
Provide feedback to plans regarding incorrect payments
Follow-up with health plans to ensure accurate reporting of claims payments
Reconcile payments and reports to ensure accurate payment from the health plans
Review monthly accruals on a periodic basis as reports are available
REQUIREMENTS
Requirements
3 Years experience in billing or claims
Excel proficiency mandatory
Access knowledge preferred
CPT-4 coding and terminology required
Previous recovery experience preferred.
Must be detail-oriented with excellent organization and follow-up skills.