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Claims Recovery Specialist
at agilon health
Honolulu, HI

Claims Recovery Specialist
at agilon health
Honolulu, HI

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Description

Job Description

The Claims Recovery Specialist is responsible for identifying, investigating and resolving claim issues including, but not limited to third party liability cases, overpayments, underpayments and claim adjustments. Professionally communicates with external and internal resources including insurance companies, other payers, providers and internal departments, to identify and resolve claim payment issues.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Pursues claims overpayments and/or reimbursements from providers and/or other parties who may be liable for payment of. Reviews and researches complex issues such as COB, Workers Compensation and/or Subrogation.
  • Determines reasons for overpayment, underpayment or other party liability.
  • Calculates amount of overpayment, underpayment or other party liability.
  • Issues refund request letters and/or lien notices. Responds to correspondence with involved parties.
  • Adjusts claims as appropriate/required based on refund, additional payment or corrected claims.
  • Complies with all policy and procedures as well as workflows. Maintains proficiency in all technical applications.
  • Ensures adherence to Medicare Compliance Policies, reimbursement policies and contract compliance.
  • Identifies, reports and maintains documentation identifying system issues.
  • Fosters and maintains open communication with other departments regarding claim processing procedures, claim denials, claim payments, and other claim related inquiries.
  • Maintains documentation of identified claim issues and works with other departments to resolve if required
  • Liaisons with other departments to resolve issues pertaining to all identified claims issues via inquiries.
  • Follows all Company policies and procedures, including but not limited to personnel policies, safety policies and operational policies as communicated by management. Follows all Department policies and procedures, including, but not limited to procedural guidelines/workflows, attendance requirements and performance requirements as communicated by management. In accordance with State and/or Federal confidentiality/privacy laws, maintains confidentiality of all company, provider, member and client information as specified by Company confidentiality policies and procedures. Represents the Company in a professional manner at all times when dealing with both internal and external customers.

 

MARGINAL DUTIES AND RESPONSIBILITIES include the following, additional duties may be assigned.

  • Assists with implementation of corrective action plans.
  • Protects and maintain user confidence and operations by keeping information confidential.
  • Adjudicates medical claims when needed.
  • Performs other duties as assigned by the Claims Supervisor or Manager.

 

EDUCATION AND/OR EXPERIENCE: High School Graduate or equivalent. One (1) year health care industry and claims experience preferred. Insurance or physician billing and/or follow up experience is highly preferred.

Company Description

The passion to change the way healthcare is delivered permeates everyone and everything at agilon health. Working together we can use our expertise to make a difference in the lives of patients and physicians alike. We can bring the joy back to practicing medicine for physicians and improve the care experience for patients across the country.

We believe that every member of our team plays a critical role in transforming care for our patients. Our customer service teams are the front line for physicians and patients navigating the system and, without our claims processing departments, our health plan partners and provider networks couldn’t do their jobs. No matter what your role is at agilon health, you can and will make a difference in the lives of the seniors and Medicaid populations we serve. Our culture and passion has already been embraced by nearly 500 employees in three states. And we are excited to welcome new members to the team as more physicians and patients experience the difference agilon health can make.

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