Claims Recovery Specialist at Prospect Medical Holdings, Inc. in Orange, California

Job Description:

The Claims Recovery Specialist is responsible for recovering incorrect claims payment to providers. Coordinates and ensures all outstanding over payments are being pursued for recovery purposes. Communicate and explain incorrect claims payments to external providers.With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.One to two (1-2) years experience in managed care. Preferably in an IPA, MSO, or Medical Group setting. Knowledge of CMS and DMHC regulations. Proficient in Excel to include the ability to create and revise Excel spreadsheets to provide accurate and clear reports.One to two (1-2) years experience in recovery and collection preferred. One to two (1-2) years previous experience examining medical Claims preferred.High School Diploma or GEDBachelors degree

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• Independently initiate contact with external providers in regards to incorrect claims payment identified by the claims audit team.
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• Clearly communicate and explain reasons for over payment and be able to independently follow up on aged recoveries.
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• Create over payment letters identified by claims auditors and internal departments.
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• Follow up letter or fax must be initiated after 30 days of the first notice sent.
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• Coordinate posting of all checks received with Claims Denial Coordinator and ensure all offset adjustment are received timely from external providers.
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• Checks and offsets received must be posted within 48 hours of receipt.
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• Assist in recovering and reconciling over payments identified by external vendors. Also responsible for contacting providers for possible offset on errors identified on claims checks in review prior to issuance of funds.
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• Independently initiate contact with external providers in regards to incorrect claims payment identified by the claims audit team.
\n
• Clearly communicate and explain reasons for over payment and be able to independently follow up on aged recoveries.
\n
• Create over payment letters identified by claims auditors and internal departments.
\n
• Follow up letter or fax must be initiated after 30 days of the first notice sent.
\n
• Coordinate posting of all checks received with Claims Denial Coordinator and ensure all offset adjustment are received timely from external providers.
\n
• Checks and offsets received must be posted within 48 hours of receipt.
\n
• Assist in recovering and reconciling over payments identified by external vendors. Also responsible for contacting providers for possible offset on errors identified on claims checks in review prior to issuance of funds.
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