Claims Recovery Analyst I - Payer

Role and Responsibilities

• Acquire knowledge of the client’s claims adjudication system(s), member and provider contracts, and client claim payment policies and procedures. 

• Assist client in identifying, validating, and recovering claim overpayments. 

• Validate claims to ensure the accuracy of algorithms and that no refund has previously been posted to the client’s system(s). 

• Review and resolve disputed overpayments from client/provider. 

• Participate in knowledge sharing to brainstorm and resolve claim issues or seek clarifications. 

• Identify new overpayment opportunities and trends by reviewing and researching areas such as CMS and Medicaid claims processing policies, adjustments by client’s internal unit/other vendors, client’s claims processing policies/system(s), provider, and member contracts. 

• Interpret and analyze medical and pharmacy claims data as well as provider and enrollment data to accurately assess and demonstrate key insights into trends and opportunities and follow concept development process. 

• Assist Management with concept approval information needed for client approval on specific trends. 

• Complete step by step instructions for each algorithm moved to production. 

• Always represent TREND and our clients in a professional manner. 

• Cooperate with team members to meet goals and complete tasks in an efficient and effective manner. 

• Provide feedback to Management regarding inventory levels, algorithm effectiveness/productivity, and new trend /ideas. 

• Collaborate with TREND Management to identify new opportunities, areas of improvement, and innovate potential solutions. 

• Escalate to the manager any situation outside the employee’s control that could adversely impact the 

             business relationship. 

• Train and assist new analysts as needed while maintaining high quality and production results. 

Qualifications

• Experience in identification, analysis, and recovery of claim overpayments 

• Bachelor’s degree in accounting, business, healthcare, or a related field 

• Equivalent work experience in a similar position may be substituted for educational requirements. 

• Excellent computer skills and proficient in Excel

• Strong communication and interpersonal skills, displaying the ability to connect and build relationships at all levels with payers, providers, clients, management, and peers.

• Strong analytical and problem-solving skills

• Effective organization, time management skills

• Must be able to learn, understand, and apply new technologies.

• High School Diploma or Equivalent Required 

Preferred Skills

• Proactive, independent and results oriented 

• Customer and team focused with a strong desire to be an active, long-term participant in the growth of the firm overall. 

• Experience with medical claims processing 

• Experience in creating and maintaining complex queries 

Mental and Physical Demands

• This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers. 

• The nature of the work is sedentary, and the employee will be sitting most of the time. 

• Essential physical functions of the job include typing and the repetitive motion to utilize computer software and hardware continuously throughout the day. 

• Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day. 

Related Duties as Assigned

• This job description documents the general nature and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. Consequently, employees may be asked to perform other duties as required. 

 

• Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information. Exemptions as provided under the ADA and TITLE VII of the Civil Rights Act will be observed and followed. 

• Reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above.