Fairfield, California20 days ago
Responsibilities: Assess, implement, and monitor activities related to recoveries and cost savings of medical claims with duties including but not limited to: Perform assessments and identify potential overpayments on claims related to all lines of business; Research and identify overpayments related to over utilization of procedures, billing procedures, potential fraudulent claims, duplicate payments, and overpayments due to lack of coordination of benefits with member's primary health care insurance policy such as a private health insurance, Medicare coverage, or an open case with CCS; Perform recovery activities associated with claim audit findings; Report dollar amounts identified for recovery, recovery amounts received, and reasons for overpayments; Responsible for identifying via reports, Medi-Cal overpayments due to retro-active Medicare or Third Party coverage and the recoupment of same. Researches and validates all provider refund checks received with duties including but not limited to: Identifies if refund check received is due to Partnership, reason for the refund; Identifies configuration or training issues related to the payment received; Recommends appropriate actions, statistical or regular adjustment, completes adjustments and reports outcome to Cost Avoidance Supervisor.