Cost Avoidance Specialist I

Under the direction of the Cost Avoidance Supervisor, the Cost Avoidance Specialist I monitors activities related to cost savings and recoveries of medical claim payments; identifies and verifies members other health coverage (OHI), updates system and recovers overpayment, and researches and validates provider refund checks. The Cost Avoidance Specialist interfaces with all departments in an information sharing capacity to promote proper payment procedures and timely cost effectiveness in claims payments.

• 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 pol i cy 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.
• Research and process all PHC product lines for COB and Third Party Liability (TPL) recoveries and communicate outcome with Cost Avoidance Supervisor.
• Prepare reports as per requirements of Department of Health Care Services (DHCS) and other regulatory or auditing agencies for Cost Avoidance Supervisor review.
• Assist with research, analysis and reports of claims as requested by management.

Researches and validates all provider refund checks received with duties including but not limited to:

• Identifies if refund check received is due to PHC, 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.
• Researches and validates other health insurance coverage of PHC members with duties including but not limited to:
• Reviews claims routes and identifies other insurance via attachments provided.
• Utilizes call center, TransUnion or DHCS website to validate the active status and type of insurance.
• Updates Amisys appropriately based upon the type, coverage dates and scope of coverage.
• Prepares reports and notification to providers of potential recovery if the insurance is found to be retroactive.

SECONDARY DUTIES AND RESPONSIBILITIES

Other Duties as Assigned

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$ 65,516.97 - $ 85,170.87

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.