- February 17, 2017
- Triple-S Salud
This position is responsible of the detection and investigation of possible cases of claim cost recovery. With the use of special tools and reports, as well as other system applications that the company may have available, the incumbent will collect evidence, document the case and will make recommendations to prevent or minimize the probability of claim cost leakage. This position will also interact with Claims, Legal, Medical Management, Network, Providers and, Compliance departments to bring the cases to final disposition and closure.
Responsible to run regularly the application or reports developed to detect possible cases of waste, claim cost overpayments, fraud or abuse and create a suspects list. Document all cases with the evidence collected and establish a dollar amount associated with the irregular activity detected. When appropriate, pursue collection of any overpayment detected as part of the irregular billing practice or billing errors committed by the provider. Recommend the implementation of Policies and Procedures, System Configuration rules or constraints that may help prevent or totally eliminate the possibility of improper claims payments. Coordinate and interact with pertinent departments to obtain evidence and understanding of identified cases in order to provide accurate facts of root cause and leakage flow. Perform and achieve the departments’ financial recovery production metrics, objectives and goals. Assisting in providing training to claims adjusters and other employees involved in claims processing. Provide updated reports on progress of investigations and recommendations for further actions. Keep a log and monitor the outcomes of cases referred to other departments or external agencies until final disposition of the cases, including follow up to achieve and ensure closure of cases. Any other tasks or functions related to the operations of the recovery units that his/her immediate supervisor my assign as part of the regular operations of the department.
Associates Degree preferable in Business Administration or at least 60-64 college credits with 1 to 3 years of experience preferable in the Health Insurance Industry. Or 3 to 5 years of this experience in lieu of. Certified as Fraud Examiner by a Recognized Organization, a plus.
The ability to add, subtract, multiply, or divide quickly and correctly in all units of measure, using whole numbers, common fractions, and decimals. Ability to an active listening, giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. Ability to communicate information and ideas in written and spoken so others will understand. Read and understand information in work related documents, and ideas presented in writing or through spoken words. Ability to communicate with MA personnel, delegated entities, providers, regulatory agencies, in both Spanish and English languages. Ability to define problems, collects data, establish facts, and draw valid conclusions. Highly organized with an exceptional attention to detail. Analytical thinker, capable of relating payment patterns, requirements and develop methods to identify potential cost leakage. Capable of conceptualizing and preforming analysis on data. Exhibit a strong understanding of all MA functional areas goals, objective, high level processes and weaknesses. All employees are expected to support actively the metrics / indicators that will facilitate the accomplishment of the corporate and departmental objectives. In any opportunity during the performance of the tasks, the employee should: Maintain the minimum professional criterion of the job, complete all required trainings, and show commitment with compliance of Company’s policies and procedures. Treat all people with respect, assuring to provide an excellent service to our policyholders, participants, providers and clients, as well as with any employee or supervisor. Maintain composure in highly stressful or adverse situations. Maintain confidential the protected information which might have access as part of the job.