Specialist, Claims Recovery (Remote)

Job Overview

This position supports claims recovery activities by conducting detailed research on payment accuracy, billing guidelines, audit findings, and federal regulations to verify overpayments and ensure provider compliance. The role involves collaborating with health plans and vendors to facilitate recovery of outstanding overpayments, managing workflow and backlog to ensure timely settlement of claims according to cost-control standards.

Key Responsibilities

• Draft overpayment notifications for providers including supportive documents such as explanations of benefits, claims, and relevant attachments.
• Maintain and reconcile reports covering collected payments, overdue overpayments, uncollectible claims, and automated payment recoveries.
• Prepare documentation for claims deemed uncollectible after thorough collection efforts to obtain write-off approvals.
• Conduct research on claims payments ranging from simple to complex cases using guidelines from the Department of Health and Human Services, Medicare billing regulations, Molina policies, and other pertinent resources to validate provider overpayments.
• Perform preliminary validations for claim offsets, including eligibility verification, coordination of benefits, standards of care, and diagnosis-related group requests.
• Accurately update multiple state recovery applications and claim systems, prepare overpayment letters, and process claims refunds or automatic debits within claim management systems.
• Adhere strictly to departmental policies and procedures, including claims processing, recovery letters, refund checks, claim adjustments, and documenting recovery activity as per Standard Operating Procedures.
• Respond to provider inquiries regarding claims recovery requests and associated remittances.
• Collaborate with finance teams to ensure timely and accurate posting of refund and manual provider payments.
• Contribute to department initiatives aimed at improving claims functionality and efficiency.
• Meet departmental standards for quality and production.
• Undertake and complete assigned basic claims projects effectively.

Required Qualifications

• A minimum of one year of clerical experience in claims or customer service roles, preferably within managed care, or an equivalent combination of education and related experience.
• Strong research and data entry capabilities.
• Excellent organizational skills and meticulous attention to detail.
• Time management skills with the ability to handle multiple projects and meet deadlines.
• Experience providing customer service.
• Effective communication skills both verbal and written.
• Proficiency in Microsoft Office and other relevant software applications.

Preferred Qualifications

• Prior experience in claims recovery roles.
• Background in health insurance within a managed care environment.

Additional Information

Current employees of Molina Healthcare should apply via the internal job portal. Molina Healthcare offers a competitive salary and benefits package and is an Equal Opportunity Employer. Pay range for this role is $13.41 to $29.06 per hour, with actual compensation influenced by location, experience, education, and skill level.