Specialist, Claims Comp & Reco

Job ID
Managed Care


Accurate and timely processing of provider appeals and Health Plan compliance reporting.  Ensure compliance with payment/denial timeliness and reporting.


  1. Resolves inquiries relative to the status of claims, member appeals, and provider disputes.  Research and verify validity of inquiries, as necessary.
  2. Maintaining compliance by closely monitoring claims that are nearing non-compliance and distributing claims inventory to examiners.
  3. Resolve claims that require medical review or may need contracting interpretation in collaboration with Medical Management and/or Contracting Staff.
  4. Submits monthly reports to health plans for delegated claims activities.
  5. Assists in staff training related to claims examining and compliance.
  6. Audits denial letter, PDRs and other claims to ensure accuracy and compliance with regulatory standards.
  7. Audits claims that have been processed daily and identifies payment errors that require correction.
  8. Organize and coordinate Health Plan regulatory audits and necessary corrective action plans.
  9. Identifies, tracks and collects on revenue recovery opportunities.
  10. Assists with printing and coordinating of checks and Explanation of Benefits mailing.
  11. Audits risk pool and health plan cap deduct data to ensure payment accuracy by third parties.
  12. Serves as a back up for Claims Manager/Director, as needed.
  13. Other duties as assigned by supervisor.


  1. High School graduate or equivalent.
  2. Minimum of seven (7) years experience required, preferably in a medical managed care environment.
  3. Certified Medical Billing Coder preferred.


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