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ADEC Healthcare works with providers and RCM teams to streamline operations and strengthen performance, allowing organizations to focus on what drives growth and progress. Our approach creates meaningful outcomes that extend beyond the system and into the communities it serves.
This is a remote-work from home position.
The Claims Recovery Specialist is responsible for identifying, investigating, and recovering overpayments made to healthcare providers within the workers' compensation industry. This role owns the recovery process from discovery through resolution, utilizing extensive workers' compensation knowledge to analyze claims, payment activity, reimbursement methodologies, fee schedules, provider disputes, and contractual requirements to maximize recovery opportunities and protect client and company assets.
The specialist independently researches complex reimbursement issues, validates recovery opportunities, conducts provider outreach, negotiates resolutions, prepares recovery correspondence, and ensures timely collection of outstanding balances. Acting as a key partner to internal and external stakeholders, this individual collaborates with providers, clients, carriers, third-party administrators (TPAs), and cross- functional teams to resolve financial discrepancies and drive successful recovery outcomes.
Success in this role requires direct workers' compensation experience, strong analytical and critical-thinking skills, exceptional attention to detail, and the ability to effectively manage a high-volume workload in a fast- paced environment. The ideal candidate possesses a deep understanding of workers' compensation claims, medical billing, provider reimbursement, overpayment recovery, appeals, reconsiderations, and regulatory requirements. They are resourceful, results-driven, and persistent in overcoming barriers, delivering financial results, and providing exceptional customer service while safeguarding company and client assets.
DUTIES AND RESPONSIBILITIES:
Identify, investigate, and validate claim overpayments made to healthcare providers.
Manage recovery cases from identification through resolution, ensuring timely follow-up and closure.
Review claims, bills, payment histories, explanations of reimbursements (EORs), contracts, and supporting documentation to determine recovery opportunities.
Prepare and send recovery letters, refund requests, and related correspondence to providers.
Conduct outbound calls and email outreach to providers to discuss outstanding recovery balances and facilitate reimbursement.
Research and resolve recovery-related inquiries, disputes, and provider concerns.
Collaborate with internal departments, including Bill Review, Accounting, Client Services, Network Services, Legal, and Operations, to support recovery efforts and resolve complex issues.
Track and document all recovery activities, communications, and outcomes in applicable systems and databases.
Monitor outstanding recoveries and maintain accurate inventories to ensure timely follow-up and escalation when necessary.
Reconcile recovered funds and support the accurate application of refunds and recoupments.
Analyze recovery trends and identify opportunities for process improvements and increased recoveries.
Maintain compliance with company policies, client requirements, contractual obligations, and applicable regulations.
Support audits, reporting activities, and special projects related to claims payment accuracy and recovery operations.
Provide exceptional customer service to both internal and external stakeholders while maintaining professional and productive relationships.
Meet established productivity, quality, accuracy, and turnaround time expectations.
Support additional operational and departmental responsibilities as assigned by management, including processing payment reversals, backing out payments, assisting with reconciliation activities, and supporting other recovery-related functions as needed.
QUALIFICATION REQUIREMENTS: To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education - High School Diploma; successful completion of continuing education in insurance, medical terminology/coding, and/or accounting preferred
Experience - 5 years customer service experience with a minimum of 5 years worker’s
compensation, healthcare, claims and/or bill review experience.
Intermediate computer experience using Microsoft Word, Excel & Outlook required
Excellent organizational skills
Knowledge of Worker’s Comp; Healthcare billing; ICD-9; CPT; RVS; U&C; Fee Schedule; HCPCS & other coding schemes preferred
Language Skills - Excellent oral communication skills and phone presence. Ability to effectively present information to providers as well as to employees of the organization
Reasoning Ability - Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret a variety of instructions and deal with abstract and concrete variables
Any combination of education, experience and knowledge that demonstrate the ability to perform the functions of the position will be accepted.
The specialist independently researches complex reimbursement issues, validates recovery opportunities, conducts provider outreach, negotiates resolutions, prepares recovery correspondence, and ensures timely collection of outstanding balances. Acting as a key partner to internal and external stakeholders, this individual collaborates with providers, clients, carriers, third-party administrators (TPAs), and cross- functional teams to resolve financial discrepancies and drive successful recovery outcomes.
Success in this role requires direct workers' compensation experience, strong analytical and critical-thinking skills, exceptional attention to detail, and the ability to effectively manage a high-volume workload in a fast- paced environment. The ideal candidate possesses a deep understanding of workers' compensation claims, medical billing, provider reimbursement, overpayment recovery, appeals, reconsiderations, and regulatory requirements. They are resourceful, results-driven, and persistent in overcoming barriers, delivering financial results, and providing exceptional customer service while safeguarding company and client assets.
DUTIES AND RESPONSIBILITIES:
Identify, investigate, and validate claim overpayments made to healthcare providers.
Manage recovery cases from identification through resolution, ensuring timely follow-up and closure.
Review claims, bills, payment histories, explanations of reimbursements (EORs), contracts, and supporting documentation to determine recovery opportunities.
Prepare and send recovery letters, refund requests, and related correspondence to providers.
Conduct outbound calls and email outreach to providers to discuss outstanding recovery balances and facilitate reimbursement.
Research and resolve recovery-related inquiries, disputes, and provider concerns.
Collaborate with internal departments, including Bill Review, Accounting, Client Services, Network Services, Legal, and Operations, to support recovery efforts and resolve complex issues.
Track and document all recovery activities, communications, and outcomes in applicable systems and databases.
Monitor outstanding recoveries and maintain accurate inventories to ensure timely follow-up and escalation when necessary.
Reconcile recovered funds and support the accurate application of refunds and recoupments.
Analyze recovery trends and identify opportunities for process improvements and increased recoveries.
Maintain compliance with company policies, client requirements, contractual obligations, and applicable regulations.
Support audits, reporting activities, and special projects related to claims payment accuracy and recovery operations.
Provide exceptional customer service to both internal and external stakeholders while maintaining professional and productive relationships.
Meet established productivity, quality, accuracy, and turnaround time expectations.
Support additional operational and departmental responsibilities as assigned by management, including processing payment reversals, backing out payments, assisting with reconciliation activities, and supporting other recovery-related functions as needed.
QUALIFICATION REQUIREMENTS: To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education - High School Diploma; successful completion of continuing education in insurance, medical terminology/coding, and/or accounting preferred
Experience - 5 years customer service experience with a minimum of 5 years worker’s
compensation, healthcare, claims and/or bill review experience.
Intermediate computer experience using Microsoft Word, Excel & Outlook required
Excellent organizational skills
Knowledge of Worker’s Comp; Healthcare billing; ICD-9; CPT; RVS; U&C; Fee Schedule; HCPCS & other coding schemes preferred
Language Skills - Excellent oral communication skills and phone presence. Ability to effectively present information to providers as well as to employees of the organization
Reasoning Ability - Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret a variety of instructions and deal with abstract and concrete variables
Any combination of education, experience and knowledge that demonstrate the ability to perform the functions of the position will be accepted.