Description
Founded in 2005, HealthSun is a local Medicare Managed Care Organization with administrative offices located in Coconut Grove, Florida. Serving more than 50,000 members, HealthSun is one of the fastest growing health plans in South Florida. As a local plan, we recognize the healthcare needs of our community and strive to provide our members with only the best service and experience possible.
Location: Miami, Florida. This is primarily a remote work from home position. However, you should reside in the Miami area as some in-office work is required.
Responsible for auditing and facilitating the recovery of claims overpayments as identified by our business partners. Responsible for research, analysis, documentation, outreach to providers, coordination of resolutions to overpayment issues, and recovery of identified overpayments.
Primary duties may include but are not limited to:
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Audits paid claims for overpayments using various techniques including systems-based queries, specialized reporting or additional research.
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Performs collection activities to ensure the recovery of overpayments and negative balance accounts.
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Works closely with contract managers to identify and correct contractual issues, if applicable.
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Conducts moderately complex case research and resolution for projects involving overpayments.
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Interprets provider contracts as they relate to overpayment opportunities and compliance with company, federal and state rules and regulations.
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Ensures high customer satisfaction when acting as a liaison between cost containment, health plans and high-profile providers in an effort to resolve overpayment recoveries.
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Assists in reviews of state complaints related to overpayments or negative balances.
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Facilitates the resolution of state complaints within strict timelines.
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Works with recovery and collection vendors to validate overpayments and vendor invoices.
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Provides feedback to modify queries, as needed.
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Performs claim and trend analysis, validation and recovery of claims payment errors.
Minimum Requirements:
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Requires a BA/BS and minimum of 4 years of experience; or any combination of education and/or experience, which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences:
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3 years of cost containment experience preferred.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
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.
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. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. 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 ability@icareerhelp.com for assistance.