Claims HMO - Cost Containment Specialist 140-1003

JOB SUMMARY:

The Cost Containment Specialist is responsible for ensuring CommunityCare receives appropriate reimbursement of payment on claims. The Specialists will take actions such as identification of outstanding overpayment of claims, collection of claim overpayments, handling third party claim liability, ensuring appropriate coordination of benefits, coordinating transplant claim processing and reporting of reinsurance claims to reinsurer.

KEY RESPONSIBILITIES:

• Generate and update database of all applicable claims which have refunds due. Run daily reports for future provider payable amounts by line of business.
• Access claims and recoup the proper dollar amount. Keep track of claims that cause negative balances and correct them as needed. Enter claim remarks of all recovery attempts and activities.
• Communicates with providers regarding outstanding overpayment amounts and keep phone log records of accounts.
• Reply to calls and emails in a timely manner. Update recoupment workflow of changes.
• Generate reports of recouped dollars by line of business as well as reporting bad debt amounts.
• Review and advise examiners on processing of transplant and Centers of Excellence claims.
• Monitor, log and track members cases for reinsurance purposes.
• Report monthly to finance and self-funded groups status of all active reinsurance members.
• Ensure correct application of coordination of benefits for our member population.
• Attempt subrogation for claims related to third party liability.
• Assist in the negotiation of settlements related to third party liability claims.
• Contribute to the creation of a pleasant working environment with peers and other departments.
• Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Generate reports and tracking of requests, receivables, savings and volumes.
• Interface with various departments regarding cost containment actions.
• Assists in researching and solving complex problems related to claim payments.
• Perform other job-related duties as assigned.

QUALIFICATIONS:

• Self-motivated and able to work with minimal direction.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes and perform claims processing procedures.
• Knowledge of claims processing manuals and health benefit booklets.
• Knowledge in the contracted managed care plan terms and rates for multiple lines of business.
• Proficient in Microsoft applications.
• Ability to perform complex mathematical calculations.
• Demonstrated learning agility
• Highly attentive to detail.
• Ability to work with a variety of individuals at all levels within and outside the company.
• Successful completion of Health Care Sanctions background check.
• Possess strong oral and written communication skills.
• Ability to organize time effectively and set priorities to meet deadlines.

EDUCATION/EXPERIENCE:

• High school diploma or equivalent required.
• Three years related work experience in claims processing, data entry or medical billing. One year of claims processing experience within CommunityCare or another healthcare environment is preferred.
• One year of collections experience preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin