Position Summary: Investigates claims data to identify overpaid/incorrectly paid pharmacy claims and initiate the recovery of that money for our clients. The position requires extensive online research in clients' claims systems, internal research materials, internet resources and phone communications with members, employers, pharmacies, providers and other insurers. Handles administrative duties, including but not limited to, invoice preparation, invoice follow-up, retractions and file maintenance.
Behavioral Skills: Displays professional behavior at all times in his or her dealings with clients, members, pharmacies, supervisors, peers and any other individuals. This applies equally to personal, written or telephone contact. Demonstrates integrity and honesty in all aspects of job performance.
Maintains all client information in strictest confidence.
- Meets, or exceeds, established invoicing and recovery goals.
- Completion of OI prime, Medicare and Post-term investigations, as assigned, to achieve annual invoicing goals as well as established monthly reversal invoicing goals and completing the required minimum number of investigations per month.
- Reviews audits/claims for other types of audits as developed by the Company.
- Maintain an overall billing accuracy rate of 95%.
- Assures all investigations and invoices are completed and documented in accordance with departmental standards. GRIP Application will be periodically reviewed and assessed for quality, aging of claims and supporting diary notes.
- Perform follow-up calls to assigned payers, pharmacies or termed members to assure timely payment of claims. Utilize the Escalation Policy and Letters on all non-cooperative payers and pharmacies and provide timely update of any payer issues. The Recovery Analyst should strive to achieve recoveries within 60 days from submission and notify Team Manager of non-cooperating members, payers and pharmacies after 60 days.
- Handle Pharmacy Appeals in accordance with the division procedures. Document and notify the Team Manager within one business day.
- Handle all member communications for collection or endorsement of funds with professionalism and in accordance with company standards and in compliance with FDCPA.
- Bring any violations or potential violations of HIPAA to the attention of the Team Manager immediately.
- Participate in the departmental discussion to identify process improvements and systems enhancements. In addition, share ideas regarding additional recovery options that may be used.
- The ability to work at our Facility and maintain our regular work schedule of Monday through Friday, 8:00 -- 5:00.
- Assist in answering inbound member calls responding to COB or Individual Post-Termination Notices. Average time per call will be assessed periodically and departmental abandonment rate should be 5% or less.