The Rawlings group, founded in 1977, is the premier leader in payment integrity services to the health insurance industry. Located in La Grange, KY, The Rawlings Group employs over 1,400 people and is growing. If you are looking for a great opportunity to make positive impact on the future of healthcare, The Rawlings Group needs to be your career choice.
The High-Cost Drug Analyst is responsible for the investigation, invoicing and recovery of overpayments of high-cost/specialty drug claims paid through medical and pharmacy systems. The analyst will also provide assistance in the development and testing of healthcare claim audits to assist clients in identifying payment errors on high-cost drug claims.
ESSENTIAL DUTIES & RESPONSIBILITIES
- Assist in the development of the process/procedures for recovery of overpayment of high-cost/specialty drugs claims.
- Assist in the research and testing of queries to refine the auditing process.
- Identify potential recoverable claims and perform investigations to determine if claims are billable.
- Assemble complete and accurate claims consistent with policies and procedures for submittal to medical provider or pharmacy for recovery.
- Perform follow-up procedures to track the status of all claims submitted for recovery. This will include preparing appropriate documentation of diary notes and monitoring recovery through final resolution. Initiate escalation procedures for those providers that will not cooperate with the recovery process.
- Process all recoveries received. This includes reconciling paid to billed amounts at claim-level and preparing required Remittance and Write-Off Reporting. In addition, perform further investigation of unidentified claim differences when applicable.
OTHER DUTIES & RESPONSIBILITIES
- Performs other duties as assigned.
SKILLS & ABILITIES
- Knowledge of high-cost/specialty drug coding, billing and claims payment processes.
- Must be a self-starter that can provide input into the development of a new system to recover high-cost/specialty drug overpayments.
- Demonstrates a high level of energy and persistence in implementing recovery processes and achieving production goals.
- Effective communication skills and the ability to influence payers that have been invoiced.
- Strong organizational skills and attention to detail in completion of responsibilities.
- Strong analytical skills with an inquisitive and creative approach to problem solving.
- Proficient in Microsoft Excel, Word and Access.