Analyst Part C/D & Recovery
Emergent Holdings

Job Info

---

SUMMARY:

The Analyst applies analytical skills and specialized knowledge to identify Medicare Part C/D members with other primary health information and pursue recovery of associated claim overpayments. The position is responsible for establishing, updating, and/or correcting Part C/D coordination of benefits (COB) records by utilizing knowledge of the Centers for Medicare and Medicaid (CMS), Medicare Secondary Payer (MSP) rules, and Part C/D Medicare plan requirements. The role also supports claim overpayment recovery and reconciliation efforts. Research and analyze data to support the reconciliation and restoration of MA plan payment reductions due to MSP status.

RESPONSIBILITIES/TASKS:

• Verifies and reconciles provider/vendor identified claim overpayments. Updates records and prepares responses to providers.
• Researches and analyzes MA Plan payment data, CMS COB data, OHI records, and CMS ECRS system to determine the validity of MSP plan payment reductions and completes actions to restore premium reductions.
• Supports the recovery of aged account receivables due to medical claim overpayments.
• Investigates Part C/D COB data and eligibility leads to identify potential COB, verify other health information, and establish MSP coordination periods. Adds, updates and/or corrects OHI records in pharmacy and medical claims processing systems including submitting COB data to CMS.
• Processes and reconciles Part D COB notification responses, and updates records accordingly.
• Analyze medical and pharmacy data to identify and pursue claim recoveries from other carriers, providers, and members, including corresponding claim and member detail, and coordinates follow up with other carriers, members, providers, and CMS as appropriate.
• Prepares, tracks, and delivers validated claim adjustment requests to appropriate vendor.
• Receives and reconciles recovery responses related to overpayments including other carrier coverage and changes in member enrollment data.
• Loads and processes checks related to recovery of overpayments. Reconciles claim adjustments and cash received to recovery submissions.
• Researches and locates CMS and/or internal policies to ensure compliance.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION:

Bachelor's degree in Business Administration, Economics, Health Care, Information Systems, Statistics, or a related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.

EXPERIENCE:

One year experience in a related field typically in at least two of the following areas/settings: health insurance, health plan operations, analysis, financial reconciliation, claim payment and recovery.

Preferred:

• Prior Part C/D COB experience preferred.
• Experience verifying coverage with carriers and applying MSP rules is preferred.
• Experience posting and reconciling claim refunds is preferred.
• Experience with claim payment recovery is preferred.
• Experience with Microsoft Access using form entry and executing queries is desired.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Ability to identify/pursue claim recoveries and reconcile claim refund payments to identified claims. Must maintain 98% accuracy.
• Ability to independently research and analyze data.
• Knowledge of MA plan operations and Part C/D recovery processes is preferred.
• Knowledge of CMS compliance guidelines, MAPD plan requirements related to COB and CMS MSP regulations.
• Ability to apply MSP regulations and make valid MSP determinations for group and non-group health plan coverage.
• Knowledge of and/or ability to research, interpret and apply Medicare and BCBSM MA Part C/D COB policies.
• Excellent written and oral communication skills.
• Knowledge of BCBSM MA claims, enrollment, imaging and other relevant systems.
• Familiar with operating desktop PC, laptop, and various printer/fax machine models and multi-functional devise machinery.
• Experience with direct customer interface including providers, members and other health plans.
• Experience with Microsoft Office products including Word, Excel, and Access.

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

PAY RANGE:

"Actual compensation decision relies on the consideration of internal equity, candidate's skills and professional experience, geographic location, market and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $51,700 and $86,546."

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.

#LI-CH1

---