Claims Recovery Examiner

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients.  ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 401k plan. Additional employee paid coverage options available.

Job purpose

The Claims Recovery Examiner position will be reviewing, requesting, and keeping record of claim refunds accurately using Access, Excel, Word, EZ Cap, and medical claims information. The candidate will need to be detail oriented to find inaccuracies, work well with large databases and calculating figures, use good communication skills to coordinate with other departments and also support the supervisor with day to day functions of the team.

Duties and responsibilities

• Complies with all Company and Department Policies and Procedures.
• When needed assist in claims audit activities.
• Review incoming recovery checks, close paid recoveries, and reach out to providers with outstanding recoveries. Assist the Finance team with matching bank transactions and bank reconciliations.
• Process and post all daily refund checks received.
• Prepares weekly and monthly reports to management of monthly refund requests and refunds received.
• Prepares monthly reports to management and IPA analysts of reconciled reports of refund checks with Accounts Receivables.
• Review refund requests for correct amount and reason.
• Extract and report claim information for data tracking.
• Preparation and mailing of refund request letters to providers.
• Updating claim notes and documentation with refund requests and refunds received information.
• Reviewing, report, and re-request letters of overpayment sent out 30 or more days.
• Investigate and follow up on claims issues regarding overpayments.
• Verify providers pending claims for recoupment by offset.
• Recover money owed by providers on claims by offset.
• Investigate and follow up on provider requests.
• Coordinate daily with multiple departments: claims, finance, IT, provider network, eligibility, and others for claims and overpayment information.
• Facilitate calls as needed to verify and/or research claims refund information.
• Ability to resolve claims issues on identified processing errors and make recommendations for improvements to avoid error
• Supports claims team members to perform any other duties upon request.
• Support other departments as needed.
• All other duties as assigned.

Qualifications

• Five years’ experience processing Commercial, Medi-Cal and/or Medicare or other government agency claims
• Service/Diagnosis coding experience
• Claims rules and regulation turn around timeframes by line of business
• Ez-Cap Experience preferred
• Proficient with all Federal and state requirements in claim processing.
• Knowledge of medical terminology and coding.
• Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe
• Detail oriented and highly organized
• Strong ability to multi-task, project management, and work in a fast-paced environment
• Strong ability in problem-solving
• Ability to self-manage, strong time management skills
• Ability to work in an extremely confidential environment
• Strong written and verbal communication skills