Analyst

• Maintain reports for tracking voluntary refunds, recoup requests and the negative vendor report
• Keeps current on all business programs, including, products offered, group contracts and certificates, provider discounts, percentages and per diems, authorizations, and other utilization management policies, etc.
• Acts as a liaison between Payment Integrity and other operational departments for claim recovery issue resolution.
• Reviews and follows up on open work items to ensure resolution is within established timeframes
• Works closely with refunds and recoveries to identify root-cause for COB related refunds and recoveries
• Assumes responsibility for accuracy, timeliness and efficiency of COB claims following established guidelines
• Assist other departments with COB/Medicare Part D appropriate claims payment questions and helps resolve claims adjudication disputes related to COB
• Identifies and reports issues with COB/MSP identification or processing training and assists in addressing COB training opportunities.
• Works professionally with members, employers, providers, other insurance carriers and CMS with regard to verification and update of member information to ensure accuracy
• Manage monthly and annual Medicare Part D letters and corresponding updates with ESI
• Responsible for complete and accurate documentation of all information received in all applicable member records and databases
• Assists leadership in decision-making and provides all relevant information accurately and timely
• Ensures department desk procedures related to role are current and complete
• Review and respond to CMS Demand Letters for group health plans
• Assists in addressing training opportunities
• Actively participates in shared accountability and commitment for departmental and organization-wide results.
• Support departmental/team goals and objectives

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Board Certified Behavior Analyst

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