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SalaryOverview:
Researches, analyzes and validates claim issues of moderate complexity against policies, procedures, benefits and claim processing guidelines. Processes claim payments and overpayment adjustments in the claims processing system to correct claim payment issues. Posts refunds in the accounting system, and reconciles accounts. Contacts providers and members to collect overpaid claims that have not systematically recovered timely. Tracks refunds and claim payment error information in the Access database to provide root cause for trend analysis. Responds directly to providers and members regarding claim payment and adjustment issues questions.
Reconciles month end recovery detail in preparation for monthly report completion.
Acts as a liaison between providers, members, Finance, Provider Network Management, Patient Financial Services, Customer Service, Appeals and Grievance and Special Investigation Unit and Claims to facilitate resolution of claim payment issues.
Responsible for meeting established turnaround times, production and recovery goals.
How you belong matters here.
Why Join Us
Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses. Maximum Offer for this position is up to: USD $22.37/Hr. Compensation Disclaimer: The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.
Now hiring a Claims Recovery Specialist
Researches, analyzes and validates claim issues of moderate complexity against policies, procedures, benefits and claim processing guidelines. Processes claim payments and overpayment adjustments in the claims processing system to correct claim payment issues. Posts refunds in the accounting system, and reconciles accounts. Contacts providers and members to collect overpaid claims that have not systematically recovered timely. Tracks refunds and claim payment error information in the Access database to provide root cause for trend analysis. Responds directly to providers and members regarding claim payment and adjustment issues questions.
Reconciles month end recovery detail in preparation for monthly report completion.
Acts as a liaison between providers, members, Finance, Provider Network Management, Patient Financial Services, Customer Service, Appeals and Grievance and Special Investigation Unit and Claims to facilitate resolution of claim payment issues.
Responsible for meeting established turnaround times, production and recovery goals.
How you belong matters here.
We value our employees' differences and find strength in the diversity of our team and community.
At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.
Why Join Us
- Full Time - Exempt: No
- Job is based Rev Hugh Cooper Admin Center
- Work hours: Days
- Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.
High School education G.E.D. required. A minimum of 2 years of experience in claims processing is required. Microsoft Word and Excel experience is required. Requires the ability to review policies, procedures, benefits and claim processing guidelines to provide detailed and comprehensive claim payment and adjustment information to the provider and member in person, via telephone, and in writing. Requires the ability to analyze reports and system processes to identify overpayments, patterns of error and trends. Strong organizational skills with the ability to meet established turnaround times, production and recovery goals. Experience in collections, account reconciliation, provider relations or customer service is preferred.
Responsibilities: - Maintains quality and prescribed standards of quantity in all research/adjustments functions.
- Sends collection letters and makes collection calls for all lines of business within a specified time frame.
- Researches and responds to all written and verbal inquiries from providers and members related to collection of overpayments in accordance with the established procedure.
- Processes claims of moderate complexity for all lines of business in accordance with established procedures.
- Researches assigned reports to ensure maximum recoveries are pursued within specified timeframes.
- Researches, adjust, and posts refund checks of moderate complexity
- Responds effectively to high priority tasks while maintaining daily activities
- Maintains daily activities of the Access database
- Identifies/researches patterns of error and inconsistencies, resolves or forwards to appropriate department for resolution and reports root cause for trend analysis.
All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
