CareFirst BlueCross BlueShield · 5 hours ago
Claims Recovery Specialist III (Remote)
United States
Full-time
Remote
Mid, Senior Level
$46K/yr - $85K/yr
7+ years expCareFirst BlueCross BlueShield is seeking a Claims Recovery Specialist III to provide validation and analysis of claims overpayments. The role involves managing overpayment recoveries, working with vendors, and collaborating with various departments to ensure effective recovery processes.
Health CareNon ProfitService Industry
No H1B
Responsibilities
Performs extensive analysis on medical policies, claim payment policies and contractual obligations for recovery inquiries and requests. Proactively investigates and performs highly complex adjustments as it relates to all cash receipts and voucher retractions. Completes all casework, documenting and summarizing information. Communicates, via phone, with vendors, members and/or providers as it relates to outstanding recovery cases. Identifies and reports problems or trends related to overpayment recovery. Identifies new concepts that will target claim overpayment scenarios
Provides oversight and support for day-to-day operations of overpayment recovery activities. Oversight includes validation/analysis of completed claims audits, approval and implementation of new overpayment recovery concepts and strategies, tracking of vendor invoice reconciliation and approval. Complete report audit activities monthly and utilizes audit information to ensure audits are conducted timely and effectively, resulting in overall achievement of targeted financial recoveries of the department
Identifies, researches, and resolves internal and external issues, ranging in complexity, which impact the vendor recovery and/or audit and recoupment programs. Monitors the causes of overpayments to identify trends, issues or other situations that may need further analysis. Works as liaison with Provider Contracting, Member/Provider Service, and our members to ensure that the recovery program operations are consistent with provider contracts as well as federal, state, and local legislative mandates. Prepares and presents information on each audit program
Coordinate and/or participate in all internal/external meetings relating to the Recovery program and/or Audit and Recoupment programs. Participates with department management in developing and revising other types of recovery programs for the organization. Identify, recommend, and/or implement actions for corporate payment policy improvements based on deficiencies uncovered in the recovery program
Serves as the primary resource for assisting the Supervisor with training new Claims Recovery Specialists and developing Claims Recovery Specialist’s I’s and II’s. Develops and maintains SOPs for Recovery Programs
Qualification
Required
High School Diploma or GED
7 years relevant experience in healthcare claims reimbursement methodologies, claims, and data analysis
A working knowledge of CPT/HCPCS coding as well as ICD9-CM diagnoses coding is necessary
Ability to resolve complex billing issues
Excellent communication skills both written and verbal
Excellent follow-up and verification skills
Ability to maintain effective interpersonal relationships
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging
Preferred
Prior vendor management, adjustment, audit, and/or recoupment experience
Benefits
Comprehensive benefits package
Various incentive programs/plans
401k contribution programs/plans
Company
CareFirst BlueCross BlueShield
CareFirst. It’s not just our name. It’s our promise.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Ja'Ron Bridges
Interim President and Chief Executive Officer
Doba Parushev
Vice President, Healthworx Ventures
Recent News
2025-10-02
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