Claims Receivables and Recovery Specialist (50627)

Summary

Western Growers is seeking a Claims Receivables and Recovery Specialist to support payment integrity and claims recovery operations. The role researches and collects claim receivables resulting from overpayments and adjustments, processes refunds and claim corrections, prepares reports and approval materials, and contributes to process improvements and audit support.

Responsibilities

• Research, review and analyze all overpayments, refunds and voids relating to medical, dental, and vision claims
• Collect receivables for the Western Growers Assurance Trust (WGAT) and clients of the Third-Party Administrator (TPA) that may be a result of overpayments or claims adjustments by researching, writing letters, and actively making phone calls
• Process refunds and perform voids and reissues as deemed necessary
• Review, research and analyze statistical data relating to claim history
• Research and respond to inquiries from other departments related to claim financial transactions within the required agreed upon turn-around-time
• Run claim open receivables report to review for new and past due overpayments
• Prepare a monthly report to the management team which provides consistent activity, tracking and performance measures as a result of collections, overpayments, refunds, voids, and allocation of all monies received
• Prepare reports for accounting to handle processing, approvals for adjustments, void, refunds
• Assure all documentation is categorized, approvals file and archived upon demand
• Support, analyze and prepare for auditors and the requested information on a timely manner
• Prepare presentations of data, clients files, and analysis to obtain approvals to adjust overpayments accordingly
• Identify and document root causes of claim overpayments
• Provide claim overpayment remediation recommendations
• Participate in ongoing process reviews to eliminate and/or decrease open receivables
• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit)
• All other duties as assigned

Skills

• High school education or equivalent and two (2) years of experience adjudicating medical/dental claims and handling claims recoveries
• Knowledge of Current Procedural Terminology (CPT) and International Classification of Diseases 10th Revision (ICD-10) and medical terminology
• Exceptional knowledge of end-user office software (e.g., Microsoft Office), with particular emphasis on Excel spreadsheets and summary analysis
• Exceptional understanding and interpretation of financial transaction and receivables systems
• Proven ability to manage timelines and commitments independently
• Excellent verbal and written communication skills
• Ability to apply critical thinking and demonstrate sound judgement in a variety of situations
• Strong attention to detail
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds
• Home router with wired Ethernet (wireless connections and hotspots are not permitted)
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site
• One (1) year of collections experience preferred
• Accounting or Receivables background preferred

Qualifications

Must Haves

• High school education or equivalent and two (2) years of experience adjudicating medical/dental claims and handling claims recoveries
• Knowledge of Current Procedural Terminology (CPT) and International Classification of Diseases 10th Revision (ICD-10) and medical terminology
• Exceptional knowledge of end-user office software (e.g., Microsoft Office), with particular emphasis on Excel spreadsheets and summary analysis
• Exceptional understanding and interpretation of financial transaction and receivables systems
• Proven ability to manage timelines and commitments independently
• Excellent verbal and written communication skills
• Ability to apply critical thinking and demonstrate sound judgement in a variety of situations
• Strong attention to detail
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds
• Home router with wired Ethernet (wireless connections and hotspots are not permitted)
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site

Nice to Haves

• One (1) year of collections experience preferred
• Accounting or Receivables background preferred

Benefits

• Fully Remote