Job Details

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Claims Recovery Specialist is responsible for processing of all identified claims overpayments within the regulatory and/or contractual timeframes. Ensures claims overpayments are recovered timely and accurately. Understands claims processing requirements which include but not limited to interpretation of contracts and benefits, correct claims coding and billing. Maintains and tracks all incoming refunds and overpayment identified internally and by the contracted recovery vendors

General Duties/Responsibilities (May include but are not limited to):

1. Reviews system generated report for potential overpayment and ensure identified claims overpayment is processed timely and accurately

2. Processes identified overpayments in designated recovery database and claims processing system timely and accurately

3. Generates and mails overpayment recovery letter/demand letter and ensures reason for recovery is clearly communicated to provider

4. Responds to provider inquiries, either telephonically or in writing, regarding overpayment refund requests

5. Collaborates with Audit team in ensuring claims payment errors which results in overpayments are recovered timely

6. Collaborates with other department in resolving potential configuration issues and updates on eligibility and other insurance information

7. Researches returned claim checks from providers/vendors, voided checks or letters from providers regarding identified overpayments

8. Assists with implementation and management of contracted overpayment recovery vendors and subrogation9

9. Works with recovery vendors in ensuring identified overpayments are accurate

10. Reviews and submits vendor invoices timely and ensure accurate payment request is submitted

11. Reviews overpaid claims and determines if root cause is due to system configuration, training issues or erroneous claims processing

12. Communicates root causes and issues that impact claims processing quality to Management

13. Generates reports based on recovery findings for training opportunities and process improvements

14. Generates weekly/monthly reports for recovery tracking and trending

15. Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance

Supervisory responsibilities:

N/A

Job Requirements:

Minimum Experience:

Required: 2+ years claims examining all types of claims (professional, facility, ancillary), preferably in Medicare Advantage delegated model

Required: 2+ years' experience in claims overpayment recovery, preferably in Medicare Advantage setting

Education:

Required: High school diploma or GED

Preferred: Bachelor's degree in healthcare management or related field

Specialized Skills:

• Knowledge of claims processing systems (EZCAP preferred)
• Working knowledge of different claims coding requirements, payment methodology (PPS, Medicare fee schedules, etc.), coordination of benefits
• Understanding of Division of Financial Responsibility on how they apply to claims processing
• Intermediate to Advance proficiency in MS Office products - Word, Access and Excel Comprehensive knowledge of Medicare Advantage claims processing requirements and other related regulatory requirements
• Knowledge of medical terminology
• Identifies and resolves problems in a timely manner
• Gathers and analyzes information skillfully

Licensure:

Required: None

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $53,210.00 - $79,815.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email ...@ahcusa.com.