Medical Claims Overpayment Recovery Specialist

Company Description

WHO IS GUIDEHEALTH? 

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.  

Join us as we put healthcare on a better path!!  

Job Description

The Overpayment Recovery Specialist is responsible for identifying, investigating, and recovering overpayments made by the company or clients. This role involves detailed analysis of claims data, provider contracts, and reimbursement processes, and requires strong analytical skills to track financial discrepancies, communicate with relevant parties, and ensure the timely and accurate recovery of funds.

WHAT YOU'LL BE DOING

• Reviewing medical claims payment data and appeals to identify and verify overpayments.
• Investigating overpayment causes, which may include duplicate payments, eligibility, system errors, or non-compliance with IPA authorization rules.
• Documenting overpayment claims, detailing the analysis, actions taken, and results of the recovery process.
• Maintaining organized records of all overpayment recovery activities for audit purposes.
• Initiating recovery processes for overpayments, including contacting healthcare providers to request refunds.
• Working with stakeholders to determine the most effective recovery method, whether through direct reimbursement, adjustments, or other means.
• Monitoring and following up on overpayment claims to ensure timely recovery of funds.
• Preparing and submitting regular reports detailing the status of overpayment recoveries, including the amounts recovered and outstanding issues.
• Tracking and documenting trends in overpayment cases and provide insights into root causes and opportunities for process improvement.
• Monitoring and tracking offset recovery on PAR provider claims and report to senior management.
• Providing clear communication with all stakeholders, ensuring timely resolution and proper documentation of recovery efforts.
• Serving as a point of contact for escalated overpayment inquiries or disputes from external parties.
• Ensuring compliance with healthcare regulations, such as HIPAA, insurance policies, and government payer guidelines.
• Adhering to company and industry policies regarding claims processing, overpayment recovery procedures, and reporting.
• Staying updated on changes in healthcare billing and reimbursement laws to ensure regulatory compliance.
• Providing excellent customer service when communicating with providers regarding overpayment issues.
• Negotiating repayment arrangements or settlements with healthcare providers, ensuring a fair and efficient resolution.

Qualifications

WHAT YOU'LL NEED YOU TO HAVE

• Minimum of 3 years of experience in healthcare billing, coding, claims.
• 3-5 years of experience in customer service collections, particularly in healthcare or insurance is preferred.
• Excellent communication and interpersonal skills for working with various stakeholders.
• Ability to work independently and prioritize tasks to meet deadlines.
• Knowledge of auditing procedures and claim resolution practices in healthcare.
• Strong analytical and problem-solving abilities.
• Attention to detail and the ability to detect discrepancies in healthcare claims and payments.
• Must have intermediate to advanced knowledge with Microsoft Office, particularly Word, Excel, and Access.
• Must be organized, self-motivated, detail oriented, disciplined and a team player.
• Demonstrates the ability to mentor staff and multi-task with minimum supervision and the ability to prioritize appropriately.

WHAT WE'D LOVE FOR YOU TO HAVE

• Bachelor’s degree in healthcare administration, business, finance, accounting, or related field
• Strong understanding of healthcare regulations, insurance contracts, and reimbursement processes.
• Analytical skills with an ability to interpret healthcare data and claims information.
• Certified Professional Biller (CPB), Certified Professional Coder (CPC), or other similar certifications.
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.
• Claim coding exper