Healthcare Billing Recovery Case Specialist I (SCA)

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs. As a Healthcare Billing Recovery Case Specialist I , you will work Group Healthcare (GHP) and/or Non-Group Healthcare (NGHP) Provider delinquent accounts under the CMS Medicare Secondary Payer recovery program. The medical billing specialist in this role will come with strong knowledge of medical claim billing, medical terminology and medical coding, forms UB04 and CMS 1500, Coordination of Benefits and Third Party Liability (COB/TPL), Medicare Secondary Payer (MSP) claims, and procedural challenges regulations; experience generating or auditing medical claims and billing; proven ability to gather and interpret Explanation of Benefits (EOB) to answer questions and resolve medical billing issues; and communicate effectively with carriers to recapture payments. What You’ll Do: Review account claim and other documentation to verify payment liability for claims that may have been paid by Medicare in error. Leverage your knowledge and expertise in medical billing/COB/MSP to review documentation and claim billing, build the case file to determine/validate liability, evaluate and respond to defenses refuting payment liability, status the account and initiate appropriate letter correspondence, answer questions and/or provide information that will bring to successful payment or other appropriate account action. Initiate correct action with applicable party (health insurance carrier, auto/home/worker’s comp insurance carrier, or legal representative) and documentation based upon payment option, actions required if new information is identified that may change the obligation to pay, or escalation in the event of refusal to pay. Updates client and/or company systems with clear and accurate information such as contact and updated demographic information, notes from contact dialog and attempts, payment commitment, as well as account status updates as applicable. Initiates applicable claim activities; follows-up and follows through accordingly to ensure documentation and activity is on-time and accurate in accordance with policies and procedures. Support internal groups or functions with interpretation of EOB (explanation of benefits), as well as development of knowledge base and understanding of key concepts and terminology in healthcare billing and claims. Arrives to work on time, works assigned schedule, and maintains regular good attendance. Follows and complies with company, departmental and client program policies, processes and procedures. Responsible for utilizing resources to ensure compliance with client requirements, HIPAA, as well as applicable federal or state regulations. Successfully completes, retains, applies and adheres to content in required training as assigned Consistently achieve or exceed established metrics and goals assigned, including but not limited to, production and quality. Completes required processes to obtain client required clearances as well as company regular background and/or drug screening; and, successfully passes and/or obtains and maintains clearances statuses as a condition of employment. (note: client/government clearance requirements are not determined or decisioned by Performant.) Demonstrates Performant core values in performance of job duties and all interactions. Correct areas of deficiency and oversight received from quality reviews and/or management. Work overtime as may be required. May be required to work some Performant holidays due to client requirement. Performs other duties as assigned. What You Bring: Minimum 6 months of medical billing experience, including Medicare, demonstrating depth of knowledge and capability required for the position. Minimum 2 years of experience in customer service, billing reclamation or recovery, or call center role demonstrating application of similar skills. High School diploma or GED is required. Knowledge and experience with medical claim billing procedures, medical terminology and medical coding, preferably in a role generating, auditing, recovery and/or researching the same. Familiarity with information in forms UB04 and CMS 1500 Experience with Coordination of Benefits, Third Party Liability, Medicare Secondary Payer Proven ability to gather and interpret Explanation of Benefits (EOB) to answer questions and resolve medical billing issues; Ability to communicate professionally and effectively with providers, carriers, beneficiaries and other audiences regarding claims and billing payment. Experience in handling Medicare and Medicaid claims. Protected patients’ privacy, understands and adheres to HIPAA standards and regulations. Remarkable interpersonal and communication skills; ability to listen, be succinct and demonstrate positive customer service attitude. Self-motivated and thrives in a fast-paced business operations department performing multiple tasks cohesively, with keen attention to detail. Proficiency using standard office technology; computer, various applications and navigation of on-line tools and resources, keyboard, mouse, phone, headset. Ability to apply knowledge learned in training from various forms (memos, classroom training, on-line training, meetings, discussions, individual coaching, etc.). Ability to follow process, procedures and regulations in the workplace. Ability to effectively perform work independently and work cooperatively with others to promote a positive team environment. Ability to adapt quickly and transition effectively to changing circumstances, assignments, programs, processes. Ability to consistently perform job responsibilities. Ability to obtain and maintain client required clearances as well as pass company regular background and/or drug screening. Completion of Teleworker Agreement upon hire, and adherence to the Agreement (including applicable policies and procedures), which includes, but not limited to, basic home office suitability requirements such as high-speed internet connectivity, appropriate work-space for compliance with confidentiality, HIPAA, safety and ergonomics, and work environment allowing dedicated work-focus without distraction during work hours. Possess a personality type that is ethical, friendly, hard-working and proactive. What We Offer: Work from anywhere in the US! Machinify is digital-first. Top Medical/Dental/Vision offerings FSA/HSA Tuition reimbursement Competitive salary, 401(k) with company match Additional health and wellness benefits and perks Flexible and trusting environment where you’ll feel empowered to do your best work The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc. We are hiring for different levels, and our Recruiting team will let you know if you qualify for a different role/range. Pay range: $19.00 - $20.00 Equal Employment Opportunity at Machinify We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/