Job Description
Job Description SUMMARY: The Analyst applies analytical skills and specialized knowledge to identify Medicare Part C/D members
with other primary health information and pursue recovery of associated claim overpayments. The
position is responsible for establishing, updating, and/or correcting Part C/D coordination of benefits
(COB) records by utilizing knowledge of the Centers for Medicare and Medicaid (CMS), Medicare
Secondary Payer (MSP) rules, and Part C/D Medicare plan requirements. The role also supports claim
overpayment recovery and reconciliation efforts. Research and analyze data to support the reconciliation
and restoration of MA plan payment reductions due to MSP status.
ESSENTIAL DUTIES AND RESPONSIBILITIES Other duties may be assigned. • Verifies and reconciles provider/vendor identified claim overpayments. Updates records and
prepares responses to providers.
• Researches and analyzes MA Plan payment data, CMS COB data, OHI records, and CMS ECRS
system to determine the validity of MSP plan payment reductions and completes actions to restore
premium reductions.
• Supports the recovery of aged account receivables due to medical claim overpayments.
• Investigates Part C/D COB data and eligibility leads to identify potential COB, verify other health
information, and establish MSP coordination periods. Adds, updates and/or corrects OHI records in
pharmacy and medical claims processing systems including submitting COB data to CMS.
• Processes and reconciles Part D COB notification responses, and updates records accordingly.
• Analyze medical and pharmacy data to identify and pursue claim recoveries from other carriers,
providers, and members, including corresponding claim and member detail, and coordinates follow up
with other carriers, members, providers, and CMS as appropriate.
• Prepares, tracks, and delivers validated claim adjustment requests to appropriate vendor.
• Receives and reconciles recovery responses related to overpayments including other carrier
coverage and changes in member enrollment data.
• Loads and processes checks related to recovery of overpayments. Reconciles claim adjustments and
cash received to recovery submissions.
• Researches and locates CMS and/or internal policies to ensure compliance.
EDUCATION AND EXPERIENCE Relevant combination of education and experience may be considered in lieu of degree.
• Bachelor's degree in Business Administration, Economics, Health Care, Information Systems,
Statistics, or a related field.
• Certification or progress toward certification is highly preferred and encouraged.
• One year experience in a related field typically in at least two of the following areas/settings:
health insurance, health plan operations, analysis, financial reconciliation, claim payment and
recovery.
• Prior Part C/D COB experience preferred.
• Experience verifying coverage with carriers and applying MSP rules is preferred.
• Experience posting and reconciling claim refunds is preferred.
• Experience with claim payment recovery is preferred.
• Experience with Microsoft Access using form entry and executing queries is desired.
OTHER SKILLS AND ABILITIES • Ability to identify/pursue claim recoveries and reconcile claim refund payments to identified claims.
Must maintain 98% accuracy.
• Ability to independently research and analyze data.
• Knowledge of MA plan operations and Part C/D recovery processes is preferred.
• Knowledge of CMS compliance guidelines, MAPD plan requirements related to COB and CMS MSP
regulations.
• Ability to apply MSP regulations and make valid MSP determinations for group and non-group health
plan coverage.
• Knowledge of and/or ability to research, interpret and apply Medicare and BCBSM MA Part C/D COB
policies.
• Excellent written and oral communication skills.
• Knowledge of BCBSM MA claims, enrollment, imaging and other relevant systems.
• Familiar with operating desktop PC, laptop, and various printer/fax machine models and multi functional devise machinery.
• Experience with direct customer interface including providers, members and other health plans.
• Experience with Microsoft Office products including Word, Excel, and Access.
Departmental Preferences: - Experience with NASCO is preferred.
PAY RANGE: Actual compensation decision relies on the consideration of internal equity, candidate's skills and professional experience, geographic location, market, and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $54,000 and $90,500.
EEO Statement: All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
Candidates are hired on an "at will" basis. Nothing herein is intended to create a contract.
Job Tags
Contract work, Work at office,