Summary of JobContinuously and proactively assess and monitor vendor operations performance to ensure contractual targets and quality expectations are met. Responsible for daily monitoring and support of all financial recovery efforts to ensure claims in a negative balance and/or overpayment identifications are recovered timely and appropriately. Work directly with special handling, Tier 1 and high exposure non special handling facilities across the enterprise. Identify areas of improvements and work with internal and external business partners to provide appropriate action plans for resolution and prevention of future claim overpayments.Responsibilities:
- Enhance recovery of claims by fostering partnerships with CCI/Emblem Providers and Provider Network Management related to overpayment and collection activity via direct provider contact.
- Ensure timely response from providers on overpayments.
- Investigate and analyze claim overpayments and discuss overpayment root cause with providers to ensure rapid closure of outstanding overpayment balances.
- Responsible for recoupment and reconciliation of negative balance opportunities.
- Conduct research and analysis of refund root cause and initiate corrective action plans for future prevention and issue resolution.
- Collaborate and work cross-functionally with other operational areas (Claims, Provider Network Management, Contract Configuration, Provider File Operations, Payment Integrity, etc.) to ensure causes of overpayments are understood and root causes are ultimately remediated.
- Collaborate with the Cognizant vendor and IT to ensure full advantage of system offset capabilities is taken to expedite recovery of overpayments.
- Analyze overpayment data to identify opportunities for improvement in financial recovery processes and reduction of overpayment root causes.
- Thoroughly investigate all possible third-party liability cases (Commercial/Medicare Insurance, Workers Comp, Motor Vehicle Insurance) that are referred by Claims Staff, Billing and Enrollment, Member Services, Provider Services, Reports or Mass Mailing Questionnaires.
- Monitor vendor COB transactional quality and deliverables.
- Analyze data to identify additional COB opportunities.
- Assess and monitor performance of vendors for each core process to meet contractual requirements and align with EmblemHealth/CCI customer experience objectives. Includes SLA performance review analysis.
- Conduct reviews, transactional audits, and compliance and operational procedure reviews.
- Make suggestions for process improvements and focused reviews to enhance vendor quality.
Qualifications:
- Bachelors Degree
- 3 - 5+ years of relevant experience in auditing and assessment activities, preferably in a healthcare provider environment (Required)
- Additional experience/specialized training may be considered in lieu of educational requirement (Required)
- Ability to independently perform research utilizing multiple sources (Required)
- Ability to discern and identify patterns/trends of issues and provide recommendations for resolution (Required)
- Facets system experience (Preferred)
- Excellent collaboration skills and the ability to influence management decisions (Required)
- Excellent communication skills (verbal, written, interpersonal) (Required)
- Strong auditing skills that be applied across all types of business problems (Required)