Be Part of an Extraordinary Team

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

Title: Financial Operations Recovery Specialist II

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Financial Operations Recovery Specialist II is responsible for the discovery, validation, recovery, and adjustments of claims overpayments. May do all or some of the following in relation to cash receipts, cash application, claim audits collections, overpayment vendor validation, and claim adjustments.

This position is tasked with conducting thorough investigations into potential other coverages, accurately determining primacy, and ensuring seamless coordination of benefits (COB) across multiple vendor clients, employer groups, and government and specialty lines of business.

How you will make an impact:

• Conduct in-depth COB investigations to establish primary and secondary coverage, utilizing NAIC, CMS, MSP, ERISA, and other federal and state regulations.

• Analyze comprehensive data sources such as COB Smart, HEW, claims, and membership data to verify coverage and resolve discrepancies.

• Maintain compliance with vendor SLAs, state and federal guidelines, and employer group contracts.

• Audits paid claims for overpayments using various techniques including systems-based queries, specialized reporting, or other research.

• Responsible for more complex issues such as coordination of benefits, Medicare, and medical policies.

• Works closely with staff from other departments on a regular basis to ensure customer satisfaction.

• Works closely with contract managers to identify and correct contractual issues when applicable.

• May perform collection activities to ensure the recovery of overpayments and maintenance of unprocessed cash and accounts receivable processes and all other cash applications as required.

• Researches voluntary refunds for accuracy.

• Requires accurate balancing of all accounts.

Minimum Requirements:

Requires a H.S. diploma or equivalent and a minimum of 2 years of claims processing and/or customer service experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• At least 2 years of experience in claims processing and customer service highly desired.

• 2 years of COB investigation experience is desired, with strong understanding and application of Medicare Secondary Payer (MSP), NAIC guidelines, ERISA, and other relevant regulations.

• AA/AS or higher-level degree in healthcare administration or insurance is preferred.

• Proficiency in Microsoft Office Suite, specifically Excel, Word, Outlook, and Teams; experience with claims processing software and SQL/data analysis tools is preferred.

• Expertise in Advanced Negotiation & Dispute Resolution, particularly in handling COB appeals and coverage disputes.

• Self-motivated with the ability to prioritize and manage high-volume caseloads, adhering to strict SLAs.

• Strong team collaboration skills, capable of working effectively within a cross-functional team while also independently managing investigations.

• Exceptional attention to detail to ensure claim adjudication accuracy, membership updates, and compliance with documentation standards.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.