Maryland Heights MO 63043 St Louis 1 14100 Magellan Plaza
Job DescriptionTo work independently, with direction from management, to conduct focused audits of all lines of business specifically for the recovery of claims overpayments. Applies overpayments or recovered dollars correctly on corresponding claim by adjusting the previously processed claim. Responsible for all activities involved in the recoupment of money from liable parties through auditing, administration of coordination of benefits, subrogation, and workers’ compensation. Directly contributes to yearly financial goals and reducing cost of care liability. Identifies claims training issues for the claims training area and provides technical expertise to claims recovery auditing using in-house claims systems.
Identify and recoup claims overpayments due to duplicate payments, terminated coverage, wrong rates, workers’ compensation, subrogation, COB. Performing necessary claim system adjustments.
Identify unique avenues for recoupment of unidentified overpayments
Monitor and maintain timeliness of requests for overpayments, adjustments for refunds received, and reissue of unsolicited refunds.
Key internal contacts include claims managers, network development management, RSC management, and claims examiners. Key external contacts include other plans for which Magellan processes claims, providers, and facilities. Work within the defined corporate and divisional goals; contract provisions, local and national legal guidelines, clinical policies related to claims adjudication as established by Magellan and Magellan’s business partners.
Knowledge, Skills, Abilities:
Other: Proven dollar recoveries through claims recovery or collections, proven record of commitment to cost containment through participation or direction of mid to large-scale projects
Experience: Experience with multiple claims platforms and multiple accounts platform; accounts receivable, accounts posting knowledge; work in Financial department.
Knowledge, Skills, Abilities: NAIC guideline knowledge
General Job Information
Job FamilyOperations Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date1/22/2019
Date Requisition Created1/21/2019
License and Certifications - Required
License and Certifications - Preferred
Other Job Requirements
Responsibilities3+ years fraud investigations/claims experienceAn understanding of contracts, business and insurance principals related to claims adjudication. Required to read and understand benefit plans. Experience with multiple claims processing systems. Knowledge of Coordination of Benefits and Workers Compensation Guidelines and Subrogation laws. An understanding of claims adjustment and the related accounting principles.Intermediate knowledge of MS Access and Excel. Working knowledge of health insurance claims payment processes. Experience administering NAIC COB regulations, Medicare Eligibility and Benefits, and Subrogation and Workers Compensation processes.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled