As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

Coordinates the reporting and collection of all outstanding receivables for all managed groups including overpayments due from providers, reimbursements for health plan programs, receivables for insured services, health plans capitation deductions and stop loss collections from the carriers. Interface with providers and payers on issues pertaining to overpaid claims and reimbursement.

Degree of Supervision:

This position reports to the Controller and requires a moderate degree of supervision to ensure tasks are appropriately prioritized.

Job Duties and Essential Functions:

• Conduct internal procedures in recouping overpayments. Address overpaid claims due to system errors, claims processing errors and discrepancies in interpreting the contractual provision. Coordinate discrepancies to departments concerned.
• Coordinate the submission of overpayment letters to providers.
• Process refund checks by coding refunds received and entering refunded amount in EZ Cap for monthly reconciliation.
• Work with the Accountant on outstanding checks and resolve with the provider for re-issue when appropriate.
• Perform special projects as received from Claims Department, Finance, Hospitals and IPAs.
• Identify insured services programs offered by the health plans, either through plan policy, health plan contracts or programs offered through the plan.
• Audit, bill and recover for insured services when the submission process is not through encounter data reporting.
• Audit, bill and recover from other products/programs offered by the health plans including pre-existing pregnancies, retro-termination, OB Kick, Injectables and other new programs.
• Submit stop loss reporting as indicated by the carrier.
• Audit stop loss payments for appropriateness of payments.
• Dispute and collect on inappropriate stop loss denials.
• Audit capitation deductions and dispute to the plan for repayment of incorrect and inappropriate deductions.
• Collect provider overpayments identified through the capitation deduction audits.
• Work with Third Party Liability vendor to coordinate recovery efforts. Track payments received from vendor.
• Automate submission and collection efforts and use like processes for new programs.
• Report processing problems and technical issues with the Claims staff, Business Solutions Group, Contract department.
• Maintain and keep in total confidence, all files, documents and records that pertain to the operation of our business and our clients.
• Perform all other job related duties as it relates to the job function or as delegated by the management team.

Physical Requirements:

Light physical effort (lift up to 10lbs). Mostly sedentary work. Regularly needs to be able to bend, stoop and reach to file.

Educational Requirements:

• Bachelor's degree in Business Administration, Finance, Accounting or related field.

Experience/Skills Requirements:

• Must have at least 5 yearsâ�� experience in the health care industry, preferably in a managed care environment.
• Solid foundation in processing and auditing of claims.
• Must be knowledgeable on the current HCFA/DOC regulatory measures.
• Must know how to identify, analyze and review reimbursement methodology, claims payment and processing application of claims.
• Must have hands-on experience in financial reconciliation.
• Proficient with Microsoft Office Software â�� Word and Excel

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.