Responsible for oversight, production and resolution of Payment Integrity (PI) recovery operations Execute and monitor recovery inventory to ensure maintenance of performance and quality levels in PI Business products and processes. Establishes procedures and techniques to achieve operational standards. Manages and mentors recovery PI staff to achieve production targets, while supporting the PI manager in resolving recovery issues in collaboration with Health Plan operations.
1. Supports implementation and execution of department initiatives that would include the following payment integrity areas: Overpayment Recovery, Pre- and Post-pay COB, Subrogation, Fraud Waster & Abuse (FWA), Data mining, Pre-pay Editing for correct coding and medical payment policies. Many of these activities include oversight and vendor inventory management/processing that are supplemental to internal processes and recovery activities.
2. Manages team members responsible for executing projects and activities involving inventory management and prioritization, information reporting, data management, procedures and workflow to ensure quality controls, and timely turnaround.
3. Prioritizes recovery processing, offset reconciliation, refund posting and reconciliation, supports provider dispute resolution, and supports claim referrals and Health Plan special projects.
4. Manages inventory production queues, assigns and prioritizes work. Ability to analyze complex data driven reports and develop actionable insights for resolution, and management reporting.
5. Assists and executes tasks and projects to ensure CMS and State regulatory requirements are met for Pre-pay Edits, Overpayment Recovery and COB and Subrogation, which improves encounter submissions, reduces G&A costs, and continues to drive positive operational and financial outcomes for all PI solutions.
6. Executes PI programs that prioritize, identify and resolve payment/recovery issues.
7. Other duties as assigned.
1. Seven years Health Plan Operations, Managed Care, and/or Provider Services required.
2. One year experience managing/supervising employees required.
3. Two years of Claims supervisory experience in health plan setting preferred.
4. Two years leading a claims recovery team preferred.
Knowledge, Skills and Abilities
1. Expertise in claims processing to facilitate claim payment issue resolution, troubleshooting payment/adjustment errors, and quality controls recovery specialist adjustment work.
2. Great communication skills to respond to Health Plan and Provider inquiries and understands when to escalate issues for resolution where appropriate.
3. Demonstrated adaptability and flexibility to a rapidly moving business environment.
4. Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services ("CMS") and the Colorado Department of Health Care, Policy & Financing ("HCPF") and the Colorado Division of Insurance.
5. Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-10, HCPC, Revenue Codes and NDC coding, HIPPA, HEDIS, NCQA, FWA .
6. Outstanding written and oral communication skills required.
7. Ability required.
Computers and Technology
1. MS Office required
2. QNXT preferred
1. Bachelor's Degree (Required)
Location Denver Health Medical Plan
Work Type Full time
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver's 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado's primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
"Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class."
Internal Number: 3521
About Denver Health
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation’s leaders in medicine.