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Sr. Claims Analyst/Supervisor in Berkeley, CA at Nelson

Date Posted: 2/13/2018

Job Snapshot

Job Description

Job Number: 2116390

The Supervisor Recovery Support will supervise, lead, train and be hands on as a
Senior Claims Analyst with a small team supporting overpayment recovery functions
with our healthcare payer clients. The recovery support function is responsible for
validating recoveries, issuance of recovery notices, fielding and initiating provider calls,
coordinating follow-up materials between payer and provider, and performing ad hoc
research on both internally developed information as well as research within payer

* Is trained on payer client's claims processing systems and in turn train other staff
on its usage, conforming to established standards for quality and timeliness.
* Review claim overpayments for missing or incomplete information; requesting
and/or researching additional information needed to complete the validation of
overpaid claims.
* Determine the correct level of reimbursement based on established benefit
criteria, coordination of benefits, state and federal regulations and related
provider contract provisions.
* Analyze and classify claim overpayment issues from identification to resolution.
This entails: validating claims processing anomalies resulting in overpayments
and offering solutions for their resolution; identifying root cause for claim
overpayments; identifying system and/or processing deficiencies and developing
recommendations for improvement; participating in and providing feedback on
overpayment identification algorithm development and testing.
* Through analysis and process improvement, assist with accuracy, timely
research, and tracking of claim recoveries and the corresponding identified
overpayments, including: Coordination of benefits/other health coverage, and
member coinsurance and deductible reimbursement requests, refunds and retrotermination
of enrollment.
* Train and supervise support staff on completing the necessary recovery letter
templates with the required information necessary to communicate to providers
the reason(s) for the request for repayment of the identified overpayment.
* Coordinate communication between provider and payer including: inbound and
outbound provider calls, faxes, emails as appropriate based on payer client
* Keep abreast of changes in state and federal regulations, program policies and
current payer client processing procedures and their implications to established
desk level procedures.

* Minimum of 10 years prior work experience in healthcare claims adjudication
operations with 7 years working as a claims analyst, minimum two years
supervisory experience, training experience a plus.
* High school diploma; college degree preferred
* Demonstrated depth of knowledge and experience in medical claims adjudication
procedures, processes, governing rules and regulations, as well as a solid
knowledge of CPT/HCPCS, ICD-10 claims coding, COB, TPL and medical
* Commercial medical claims processing experience, experience with Medicare
claims processing and reimbursement rules and requlations, Medicaid or Medi-
Cal a plus.
* Solid understanding of standard claims processing systems and claims data
* Excellent communication skills; verbal and written
* Strong MS Office skills (Word, Excel, PowerPoint)
* Prior experience auditing claim payments against established policies and related
provider contract language, specifically to identify improper payments
* Hands-on working knowledge and background using claims processing
system(s). Facets and QNXT application (V. 4.81 or later) experience preferred
* Experience in HIPPA/HiTech and the Affordable Care Act processing
* Detail oriented with problem-solving abilities and ability to maintain strict
* Strong organizational, time and project management skills and multi-tasking
* Excellent qualitative and quantitative abilities
* Ability to work in a fast-paced environment and handle multiple priorities.

About Nelson:

For more than 45 years, we've been passionate about helping people find jobs they love - rewarding jobs that further career goals. At Nelson, we partner with companies that have outstanding reputations. Working with innovative startups to Fortune 500 companies, our skilled recruiters have access to opportunities beyond what you can find on your own.

With Nelson, you'll get the most out of your career. Together, we'll set career goals and find you a position where your skills shine. Whether you are looking for a position in: accounting & finance, administration, computer gaming, digital media, engineering, human resources, legal, light industrial, manufacturing, or technology, Nelson helps place people in full-time, temporary, temp-to-hire, project, and contract positions. For a full listing of jobs, go to: and click "Find Work."