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Emergent Holdings · 1 day ago

Analyst Part C/D & Recovery

Detroit, MI

Full-time

Onsite

Entry Level

$54K/yr - $90K/yr

1+ years exp

Emergent Holdings is seeking an Analyst to apply analytical skills and specialized knowledge in identifying Medicare Part C/D members and recovering associated claim overpayments. The role involves establishing and updating coordination of benefits records, supporting claim overpayment recovery, and analyzing data to restore payment reductions due to Medicare Secondary Payer status.

Health CareInformation ServicesInformation TechnologyInsuranceMedical

Comp. & Benefits

Responsibilities

Verifies and reconciles provider/vendor identified claim overpayments. Updates records and prepares responses to providers

Researches and analyzes MA Plan payment data, CMS COB data, OHI records, and CMS ECRS system to determine the validity of MSP plan payment reductions and completes actions to restore premium reductions

Supports the recovery of aged account receivables due to medical claim overpayments

Investigates Part C/D COB data and eligibility leads to identify potential COB, verify other health information, and establish MSP coordination periods. Adds, updates and/or corrects OHI records in pharmacy and medical claims processing systems including submitting COB data to CMS

Processes and reconciles Part D COB notification responses, and updates records accordingly

Analyze medical and pharmacy data to identify and pursue claim recoveries from other carriers, providers, and members, including corresponding claim and member detail, and coordinates follow up with other carriers, members, providers, and CMS as appropriate

Prepares, tracks, and delivers validated claim adjustment requests to appropriate vendor

Receives and reconciles recovery responses related to overpayments including other carrier coverage and changes in member enrollment data

Loads and processes checks related to recovery of overpayments. Reconciles claim adjustments and cash received to recovery submissions

Researches and locates CMS and/or internal policies to ensure compliance

Qualification

Medicare Part C/D knowledgeCMS compliance guidelinesClaim payment recoveryFinancial reconciliationMicrosoft AccessData analysisCustomer interface experienceMicrosoft Office proficiencyResearch skillsCommunication skills

Required

Bachelor's degree in Business Administration, Economics, Health Care, Information Systems, Statistics, or a related field

One year experience in a related field typically in at least two of the following areas/settings: health insurance, health plan operations, analysis, financial reconciliation, claim payment and recovery

Ability to identify/pursue claim recoveries and reconcile claim refund payments to identified claims. Must maintain 98% accuracy

Ability to independently research and analyze data

Ability to apply MSP regulations and make valid MSP determinations for group and non-group health plan coverage

Excellent written and oral communication skills

Familiar with operating desktop PC, laptop, and various printer/fax machine models and multifunctional devise machinery

Experience with direct customer interface including providers, members and other health plans

Experience with Microsoft Office products including Word, Excel, and Access

Preferred

Certification or progress toward certification is highly preferred and encouraged

Prior Part C/D COB experience preferred

Experience verifying coverage with carriers and applying MSP rules is preferred

Experience posting and reconciling claim refunds is preferred

Experience with claim payment recovery is preferred

Experience with Microsoft Access using form entry and executing queries is desired

Knowledge of MA plan operations and Part C/D recovery processes is preferred

Knowledge of CMS compliance guidelines, MAPD plan requirements related to COB and CMS MSP regulations

Knowledge of and/or ability to research, interpret and apply Medicare and BCBSM MA Part C/D COB policies

Knowledge of BCBSM MA claims, enrollment, imaging and other relevant systems

Experience with NASCO is preferred

Company

Emergent Holdings

Emergent Holdings’ elite team makes lives, companies and communities better! Emergent Holdings is driven by a singular goal — improving the health and safety of our customers and our communities.

Founded in 2000

Lansing, Michigan, USA

1001-5000 employees