Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Provider Recovery Auditor is responsible for the audit and recovery of claims overpayments including COB and third-party liability. Major Functions (Duties and Responsibilities)
1. Initiate and expand recovery opportunities through provided audit results, Provider calls, Third Party Liability and CCS eligible services.
2. Audit payment errors that result in Provider refund checks to properly apply funds and determine the root cause.
3. Communicate with and answer Provider inquiries and/or Provider Disputes regarding the reason for the refund request based upon claims processing guidelines, contractual agreements involving the use of established payment methodologies, Division of Financial Responsibility, and regulatory guidelines.
4. Promote teamwork and maintain effective working relationships with others throughout the organization. Supervisory Responsibilities Leading: Self Experience Qualifications
Four (4) years claims processing experience including Medicare and Medi-Cal. Two (2) years of experience auditing claims in a managed care environment including contract and financial DOFR interpretation. Experience with MS Office applications. Preferred Experience Education Qualifications
High school diploma or GED required. Preferred Education
Bachelor’s degree from an accredited institution preferred. Professional Certification Professional Licenses Drivers License Required No Knowledge Requirement
Knowledge of Medi-Cal and CMS guidelines for claim payments. Skills Requirement
Strong analytical and problem-solving skills. Must be able to review cause and impact of problems and recommend realistic solutions both in writing and in meetings. Microsoft Office including being able to manipulate large data sets in Excel files. Excellent oral and written communication skills. Abilities Requirement
Ability to build successful relationships across the organization. Commitment to Team Culture
The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization. Working Conditions
Sedentary work in an office environment. Physical Requirements Keyboarding: Traditional – FREQUENTLY Keyboarding: Other – FREQUENTLY Use of computer mouse – FREQUENTLY Hearing: One-on-One – FREQUENTLY Hearing: In a group – FREQUENTLY Hearing: Over the Telephone/Cell Phone – FREQUENTLY Hearing: Conference Speakers/Video Calls/Radio Calls – FREQUENTLY Turning/rotation of wrist or hand – FREQUENTLY Communicate: Information/ideas verbally – FREQUENTLY Alternate Sit/Stand or Walk at Will – FREQUENTLY Near Visual Acuity – FREQUENTLY Sitting – FREQUENTLY Lighting – CONSTANTLY Indoors – CONSTANTLY Perform complex and varied tasks – FREQUENTLY Develop and maintain positive work relationships – CONSTANTLY Regular contacts: co-workers, supervisor – FREQUENTLY Decision-making – FREQUENTLY Lead/Influence Others – FREQUENTLY Work review – FREQUENTLY Rapid Pace of work – FREQUENTLY Control of work pace – FREQUENTLY Problem Solving – FREQUENTLY Memory – FREQUENTLY Understand and follow direction – FREQUENTLY Regular and reliable attendance – CONSTANTLY
Starting Salary: $53,885.31 – $68,701.57
Pay rate will commensurate with experience
Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.