Under the direction of the Sr. Internal Auditor, this position is responsible for leading, and
supervising the HealthPlan’s Cost Avoidance and Recoveries Team. Monitors and audits any
payment that may be outside the HealthPlan’s current provider contracts or State contract.
Identifies overpayments for recovery; researches and adjusts provider refund checks; identifies,
verifies, and updates core claims system with members’ other health insurance coverage
information; and performs post-payment audit functions in collaboration with Internal Audit.

• Works collaboratively with the Finance, Member Services, Provider Relations, Health
  Services, and Claims departments.
• Leads the Cost Avoidance and Recoveries Team to assess, develop, implement, and
  monitor activities related to cost savings and recoveries of medical claim payments.
• Provides direction and guidance to direct reports. Responsible for supervision, including
  timecards, performance discussions, mentorship, evaluations and development plans.
• Prioritizes and delegates cost avoidance and recoveries tasks and projects.
• Directly oversees the quality of work performed by the Cost Avoidance and Recoveries
  Team.
• In collaboration with Internal Audit, performs timely post-payment claim audits for
  payment accuracy.
• Ensures that the Cost Avoidance Team performs research, analysis, and reporting of
  claims, as requested by Management.
• Monitors the Team’s research and possible adjustment of claims from Provider refund
  checks received.
• Reports dollar amounts identified for recovery, recovery amount received, and reasons
  for overpayments to the Sr. Internal Auditor.
• Oversees and identifies process and design reporting tools to identify risk areas
  requiring audit research and actions.
• Supervises all aspects of the Coordination of Benefits (COB) between the HealthPlan
  and members’ primary health care insurance, such as private health insurance, Medicare
  coverage, or an open case with California Children’s Services (CCS).
• Oversees the preparation of monthly reporting to Department of Health Care Services
  (DHCS), conveying members’ other health care coverage.
• Identifies process improvement opportunities across all areas within position purview.
  Makes recommendations and implement approved changes to maximize efficiency and
  quality of analytic work.
• Interfaces with all departments in an information sharing capacity to promote proper
  payment procedures and cost effectiveness in claims payments.
• Develops new and existing staff while enhancing the training materials, methods and
  systems.
• Participates in the development of departmental policies and procedures
• Participates in committees, task forces, work groups and/or multidisciplinary teams.
• Provides backup for the Cost Avoidance and Recoveries Team by personally performing
  all duties related to the Team’s scope of work.

Secondary Duties and Responsibilities

• Coordinates with other departments in collecting raw data and publishing reports for
  both internal and external needs.
• Participates in special projects and assignments as needed.
• 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:

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.