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Supervisor Claim Payment and Recovery in Southfield, MI at AF Group

Date Posted: 7/1/2018

Job Snapshot

Job Description

COBX - Senior Health Services



SUMMARY:



Responsible for supporting and providing oversight of all activities related to medical claim overpayment recovery/avoidance initiatives and vendor operations for contracted recovery services. This position will supervise and support team members and act as a liaison between corporate business areas and lead group or committee discussions. This position will serve as the lead for research, analysis, identification, evaluation, and tracking of claim overpayment recovery concepts and avoidance initiatives. This position reports to the Manager, COB and Recoveries.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.


  • Manage audit concept review, approval, and tracking process. Prepare and present audit concepts to internal business areas.


  • Manage claim overpayment validation, recovery inventory, and reporting.
  • Support vendor invoice reconciliation efforts.
  • Lead vendor oversight and operations for contracted recovery services.
  • Hire, supervise, coach, mentor, and develop team members.
  • Lead the implementation of claim overpayment recovery and cost avoidance initiatives.
  • Collaborate and communicate with Medicare operational leaders, vendors, and support areas on claim recovery and cost avoidance initiatives.
  • Establish, monitor, track, and report routine audit outcomes related to the recovery of medical claim overpayments.
  • Understand and apply CMS guidance with respect to MA program regulations, Medicare claims processing policy, and industry billing practices to identify claim overpayment recovery opportunities.
  • Lead complex projects with cross-functional teams

    DIRECTION EXERCISED:

    Directly supervises exempt staff in accordance with company policies and applicable Federal and State Laws. Responsibilities include but are not limited to effectively interviewing, hiring, terminating, and training employees; planning, assigning and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems; supporting and encouraging the engagement process.





    EMPLOYMENT QUALIFICATIONS:



    EDUCATION OR EQUIVALENT

    EXPERIENCE:



    Bachelor's Degree in Business Administration or related field. Equivalent relevant combination of education and experience may be considered in lieu of degree. Certification or progress toward certification is highly preferred and encouraged.





    EXPERIENCE:



    Five years of work experience in a Medicare Advantage Plan, managed care environment, CMS payer role , medical claim recovery vendor or as a consultant providing medical claim recovery analysis to managed care organizations. A minimum of one year demonstrated leadership experience is required.




  • Experience with Medicare claims processing, auditing or payment verification for medical services.
  • Prior experience with vendor relations.
  • Prior experience managing workflow.
  • Medicare Advantage plan operation experience is preferred.
  • Leading and facilitating cross functional work groups or committees.
  • iKA claims system experience is desired.
  • Prior experience supervising direct reports is preferred.









    SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:




  • Knowledge of Medicare claim payment policy, claim industry standards, and familiarity with CMS guidance with respect to MA plan operations is preferred.
  • Ability to research and apply Medicare payment policy, claim industry standards, and CMS regulations related to MA plans.
  • Ability to collaborate and reach agreement with internal stakeholders
  • Excellent analytical, organizational, research, verbal and written communication skills.
  • Ability to work effectively in a team environment.
  • High level of proficiency in use of existing software packages (Access, Microsoft Word, Excel, Outlook, etc).
  • Ability to multi-task and prioritize work assignments.
  • Ability to write in a clear, concise and grammatically correct manner and be able to translate complex requirements into language understandable by the general public.



    This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.





    Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
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