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Purpose:
•  Responsible for collecting overdue payments and establishing re-payment arrangements.

•  Negotiates liability settlement of medical claims with third parties or healthcare providers; seeks reimbursement from healthcare providers and/or ensures payment of claims by appropriate insurance carrier.


Scope:
General:
•  Uses best practices and knowledge of internal or external business issues to improve products or services

•  Acts as a resource for colleagues with less experience

•  Requires in-depth knowledge and experience

•  Decisions guided by policies, procedures and business plan

•  Generally domestic scope/accountability


Primary Responsibilities:
•  May perform one or more of the following duties:

•  Settles the health plan’s subrogation (i.e. third party liability claim) and reimbursement interest; negotiates with the service provider, insurance attorney, insured, etc.  in pursuit of recovering payments for services that should have been paid by another party

•  Applies legal principles and practices of subrogation to maximize recoveries

•  Analyzes and reviews paid medical claims to ensure the recovery amount is consistent with settled agreement

•  Applies coordination of benefits (COB) practices to minimize overpayment by client

•  Perform onsite auditing of healthcare providers’ accounting records to identify and recover overpayments made by client

•  Reviews and interprets employee benefit plan language or insurance contracts to ensure the plan rights are adhered to

•  Ensures compliance with federal, state and local legislation regarding reporting and privacy issues

•  All other duties as assigned

•  In addition to the above, the Sr. Recovery Analyst will also perform one or more of the following:

•  Provides analyses and recommendations on service delivery improvements, performance metrics and enhancements to productivity

•  Trains and develops newly hired Recovery Analysts in assigned territory

•  Provides quality assurance audit and feedback to Recovery Analysts in assigned territory

•  Manages ad hoc projects requested by internal client