Cost Avoidance Specialist I

Overview

Under the direction of the Cost Avoidance Supervisor, the Cost Avoidance Specialist I monitors activities related to cost savings and recoveries of medical claim payments; identifies and verifies members other health coverage (OHI), updates system and recovers overpayment, and researches and validates provider refund checks. The Cost Avoidance Specialist interfaces with all departments in an information sharing capacity to promote proper payment procedures and timely cost effectiveness in claims payments.

Responsibilities

• Assess, implement, and monitor activities related to recoveries and cost savings of medical claims with duties including but not limited to:
• Perform assessments and identify potential overpayments on claims related to all lines of business;
• Research and identify overpayments related to over utilization of procedures, billing procedures, potential fraudulent claims, duplicate payments, and overpayments due to lack of coordination of benefits with member's primary health care insurance policy such as a private health insurance, Medicare coverage, or an open case with CCS;
• Perform recovery activities associated with claim audit findings;
• Report dollar amounts identified for recovery, recovery amounts received, and reasons for overpayments;
• Responsible for identifying via reports, Medi-Cal overpayments due to retro-active Medicare or Third Party coverage and the recoupment of same.
• Research and process all Partnership product lines for COB and Third Party Liability (TPL) recoveries and communicate outcome with Cost Avoidance Supervisor.
• Prepare reports as per requirements of Department of Health Care Services (DHCS) and other regulatory or auditing agencies for Cost Avoidance Supervisor review.
• Assist with research, analysis and reports of claims as requested by management.

Researches and validates all provider refund checks received with duties including but not limited to:

• Identifies if refund check received is due to Partnership, reason for the refund;
• Identifies configuration or training issues related to the payment received;
• Recommends appropriate actions, statistical or regular adjustment, completes adjustments and reports outcome to Cost Avoidance Supervisor.
• Researches and validates other health insurance coverage of Partnership members with duties including but not limited to:
• Reviews claims routes and identifies other insurance via attachments provided.
• Utilizes call center, TransUnion or DHCS website to validate the active status and type of insurance.
• Updates Amisys appropriately based upon the type, coverage dates and scope of coverage.
• Prepares reports and notification to providers of potential recovery if the insurance is found to be retroactive.

SECONDARY DUTIES AND RESPONSIBILITIES

Other Duties as Assigned

Qualifications

Education and Experience

High School Diploma or equivalent and minimum two (2) years’ experience in health care including experience in processing claim in an automated claims environment, working knowledge of medical terminology, and related procedure and diagnostic coding (CPT-4, ICD-9, ICD-10, HCPCS); or equivalent combination of education and experience. Experience in Medi-Cal operations, Amysis, COB, Reinsurance, and claims billing procedures preferred.

Special Skills, Licenses and Certifications

Ability to accurately and efficiently perform 10-key by touch required and working knowledge of windows-based PC applications including word processing, spreadsheets, and database management; ability to use MS Word and Excel required. Must possess excellent organizational skills and excellent problem solving skills. Must be proficient in math skills. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Working knowledge of Medi-Cal billing requirements preferred. Working knowledge of claims procedures in a health-based system. Ability to interpret and analyze Explanation of Benefit forms related to primary health insurance policies. Working knowledge of claim types including but not limited to inpatient, outpatient, cross over, FFS, ER, RX, CCS FQHC, DME, and LTC/Hospice. Working knowledge of Medicare billing requirements preferred. Working knowledge of medical terminology. Ability to design and produce reports from database reporting tool (Discoverer preferred). Ability to format and produce professional business correspondence. Ability to process all claims types comprehensively, accurately, and efficiently. Ability to communicate effectively, both orally and in writing. Ability to accurately complete tasks within established time frames. Must have high level of accuracy in detail oriented tasks. Ability to effectively prioritize multiple tasks and deadlines. Ability to maintain confidentiality. Must have the ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position.

Work Environment And Physical Demands

Must have the ability to establish and maintain effective and cooperative working relationships with Partnership staff and others contacted in the course of work. Ability to use a computer keyboard. Working knowledge of and ability to operate general office equipment including computer, telephone, photocopy machine, fax machine, etc. Ability to spend more than 70% of work time in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 10 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$80,140.53 - $100,175.67

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.