Recovery Specialist

Why Choose Jefferson Health Plans? We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential. While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ. Perks of JHP and why you will love it here: Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing  Flextime and Work-at-Home Options Benefits & Wellness Program including generous Time Off  Impact on the communities we service  We are seeking a talented and enthusiastic Recovery Specialist to join our team! The Recovery Specialist uses other coverage resource data, internal and external audits, and claim file analysis to identify claim overpayments and pursue recovery. Assist the Business Unit with the identification of appropriate business solutions to problems including root cause analysis and analysis of alternative options and organizational impact to ensure resolution to repetitive issues are addressed in a timely and accurate manner. Maintain accurate department records and documentation for all assignments. Reviews all supporting documentation received from internal and external entities are complete and accurate. The Recovery Specialist supports corporate goals by ensuring that activities and outcomes are in compliance with HPP, client and government contracts and internal strategies.   As the Recovery Specialist your daily duties may include: Uses other coverage resource data, internal and external audits, Claim Check software, and claim analysis to identify and pursue recovery of overpayments. Analyzes root cause of overpayments and interacts with other units and departments to take appropriate corrective action. Compares relevant data (Department of Human Service (DHS) third party liability (TPL) files, Centers for Medicare & Medicaid Services (CMS) insurance coverage files, internal/external audits) to claim file data to determine situations when inappropriate overpayments were made and recommend preventive action to avoid reoccurrence. Pursues recovery of inappropriate overpayments, and apply recoveries to the claims payment system. Communicates to Enrollment Department any updates to TPL/coordination of benefits (COB) files within claims system to correctly reflect other coverage resources that would cause HPP to avoid making payment as the primary coverage. Communicates to DHS/CMS any third party liability or lien discovery that would cause the State to be able to avoid payment or subrogate, and support all requests for additional information and documentation. Collects overpayments for all liens in situations where another insurer has made payments (auto accidents, etc.). Responds to claim inquiries and suspended claims regarding HPP’s role as primary or secondary payer. Requests claim and medical records from other insurers, providers and members. Tracks and reports recoveries and outstanding balances. Assists in the preparation of savings and recovery reports. Qualifications High school diploma-Required Experience in Managed Care Operations and/or 2 years claim processing experience, and 2 years coordination of benefits, subrogation and/or recovery-Preferred.  Skills, We Value: Demonstrates experience with and understanding of managed care operations department and system module interdependencies. Excellent written and verbal communications skills for use with internal and external clients. Exhibits technical skills with the ability to coordinate and manage multiple, concurrent projects and pays attention to detail. Strong working knowledge of supported applications. Maintains accurate logbooks, work sheets, and records of procedures, results and problems. Has a broad understanding of departmental policies, procedures, functions, workflows, etc. Documents and understands business process flows and inter-departments dependencies. Strong problem solving, analytical and research skills. Demonstrated interpersonal, oral and written communication skills. Strong working knowledge of MS Excel, Word, Access and/or other database applications. Ability to interface with all levels of management