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About the Role

Review medical and pharmacy claims, eligibilities, and supporting medical documents to identify contestation and recovery opportunities with Health Plans. Monitor, track, and report the success of the contestation process.

Responsibilities

• Review medical and pharmacy claims data, eligibility files, and medical documents to identify contestation opportunities.
• Create, improve, and maintain contestation Policy and Procedures.
• Track and monitor eligible claims for contestation on a weekly/monthly basis.
• Establish effective communication with Health Plans.
• Submit contestation requests and supporting documentation to Health Plans within established filing deadlines and contractual requirements.
• Work closely with Network and Contracting department to review and recommend changes based on claims behavior.
• Report to Network and Contracting on open contestation cases, recoveries, aging, trends, and financial impact.
• Create and maintain tracking reports.
• Analyze complex healthcare claims, eligibility, and pharmacy data regarding healthcare costs and utilization, and make recommendations.
• Keep record of contestation submissions, supporting evidence, correspondence, recoveries, and payment outcomes.
• Ensure compliance with Health Plan requirements, contractual obligations, regulatory guidelines, and internal policies related to contestation activities.
• Perform other duties as assigned.

Requirements

• Bachelor’s degree in business, finance, computer science, engineering, economics or related field preferred.
• At least 3-5 years of professional experience in claims-based healthcare analytics with a payer, provider, or related healthcare entity.
• Value-based care experience preferred.
• Certified Subrogation Recovery Professional (CSRP) certification is a plus.
• Familiarity with healthcare reimbursement methodologies and calculations such as DRGs, Revenue Codes, CPT Codes, bundled payments.
• Knowledge of health insurance financial business cycle, healthcare quality reporting, and benchmarking.
• Knowledge of healthcare claims; differences between institutional vs professional billing and various sites of care/service.
• Advanced or higher proficiency in Microsoft Excel.
• Experience with Power BI, Tableau, or Microsoft SQL preferred.
• Bi-lingual Spanish/English preferred.

Skills

• Possess personal qualities of integrity, credibility, and commitment to corporate mission.
• Thoroughness and attention to detail.
• Ability to work independently and complete assignments within instructions, routines, and accepted practices.
• Excellent people skills, with an ability to partner with a dynamic leadership team.
• Flexible and able to multitask; can work within an ambiguous, fast-moving environment, while driving toward clarity and solutions.
• Demonstrated resourcefulness in setting priorities and guiding investment in people and systems.
• Ability to work with individuals within and outside the organization in a professional and courteous manner.
• Demonstrated ability to successfully plan, organize and manage projects.
• Organized and able to manage competing priorities.
• Resourcefulness in problem solving.
• Detail and financial oriented.
• Strong written and verbal communications skills.
• Highly flexible; able to accommodate changing needs of the department.

Experience Level

• 3-5 years of professional experience

Education Level

• Bachelor’s degree in business, finance, computer science, engineering, economics or related field preferred
• Certified Subrogation Recovery Professional (CSRP) certification is a plus