COB, Recovery, Provider Appeals and Reconciliation Specialist

4 days ago

Manila, National Capital Region, Philippines TakeCare Asia Philippines, Inc. Full time

Experience and Specifications:

  1. Graduate of any medical related degree – License is not required
  2. Minimum of 3-year related experience in identifying, coordinating and determining Medicare and other insurance coverage. Related experience on recovery opportunities in cases where TPL/COB exists and/or provider overpayments based on standard policies, procedures and guidelines.
  3. Minimum of 1-year related experience in provider appeals and reconciliation.
  4. Effective team player with very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.
  5. Must have behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling irate customers.
  6. Outstanding oral and written communication skills.
  7. Strong ethics and a high level of personal and professional integrity.
  8. Must have basic familiarity with federal and state laws and requirements relating to healthcare management.
  9. Computer literate and very highly proficient in using MS office programs.
  10. High degree of skill in nonverbal, oral and written communications.
  11. Ability to identify, define and explain complex business problems and the persuasion skills necessary to implement solutions to those problems.
  12. Level of Responsibility: Direct, but minimally supervised, impact on quality and efficiency of services or operation of company or revenues/expenses. Permitted to make decisions on moderately complex problems/issues.
  13. Provides recommendations to management regarding complex cases/decisions.

Essential Duties and Responsibilities:

  1. Subrogation/Coordination of Benefits
    1. Conducts investigation for all possible Medicare and other insurance COB information utilizing the Medicare verification telephone hotlines/MSP line and contacting other insurance carriers.
    2. Identifies potential COB claims and determines COB hierarchy for claims processing.
    3. Updates member records in FACETS/Claimscape for Medicare and other insurance coverage for any TakeCare member.
    4. Conducts investigation of any potential TPL/COB potential recovery as part of claims process.
    5. Researches and monitors cases with potential/identified subrogation opportunities, prepares recovery reports and pursues any potential recoveries and provider overpayments.
    6. Provides recommended recovery settlement and obtains approval for any settlement within the established authority.
  2. Provider Appeals
    1. Responsible for logging and sending acknowledgement letter within 5 business days from receipt of any provider payment or claims appeal.
    2. Reviews any provider appeals and disputes based on submitted documentation and information vis-à-vis established TakeCare benefit coverage, coding and payment guidelines.
    3. Provides expertise and claims support by reviewing, researching, investigating, and providing recommendations to resolve all types of claims and provider appeals as well as recovery strategies.
    4. Verifies member plan benefit information and provider contract vis-à-vis appeals and summarizes and prepares information and documentation to respond and resolve any appeals.
    5. Communicates directly with providers regarding any payment or claims disputes including coordination on additional information and documentation.
    6. Reviews and resolves provider disputes in a timely manner consistent with TakeCare guidelines, policies and standards.
    7. Prepares written communication to the provider regarding the final decision on the appeal.
    8. Prepares and sends invoices and statements for identified member accounts receivables.
    9. Contacts members within seven (7) days after sending invoice or statement to verify if received and communicate with member on the information relating to the amount due. Creates a payment plan with the member on how to pay the outstanding amount.
  3. Cost Containment and Recovery
    1. Prepares documentation on member records in FACETS/Claimscape regarding actions taken and payment plan agreement. Follows up on payment status according to agreed payment plan.
    2. Prepares management report with detailed information on any outstanding accounts receivables and collected payment each month.
    3. Coordinates and works with the respective claims processors/examiners on any provider overpayments to ensure necessary adjustments are made in FACETS/Claimscape and prepares and maintains tracking reports for provider overpayment recovery. If claims from the provider are not received within thirty (30) days for the offset, prepares communication to provider to request payment of any overpayment.
  4. Provider Reconciliation
    1. Coordinates and works with the respective claim processor/examiner on any provider reconciliation and ensures these reconciliations are completed and presented to the provider for resolution.
    2. Ensures any outstanding claims based on the outcome of the reconciliation are processed and paid to the provider based on performance goals and expectations.
  5. Performance and Goal Expectations
    1. Meets performance goals and objectives as defined by Management on COB, recoveries, provider appeals and reconciliation.
    2. Provides regular reports to management on performance goals and expectations.
    3. Processes any provider and/or member claims that may be assigned.
    4. Performs other duties as may be assigned.
#J-18808-Ljbffr

  • Provider Payment Resolution Specialist

    4 days ago

    Manila, National Capital Region, Philippines TakeCare Asia Philippines, Inc. Full time

    About the RoleWe are looking for a detail-oriented Provider Payment Resolution Specialist to join our team at TakeCare Asia Philippines, Inc. The successful candidate will be responsible for resolving provider payments and ensuring that our members receive the support they need.Key Responsibilities:Coordinates and works with the respective claim...

  • Claims Specialist

    4 days ago

    Manila, National Capital Region, Philippines TakeCare Asia Philippines, Inc. Full time

    Job DescriptionWe are seeking a highly skilled Claims Specialist to join our team at TakeCare Asia Philippines, Inc. As a Claims Specialist, you will play a crucial role in ensuring the accuracy and efficiency of our claims process.Key Responsibilities:Investigate all possible Medicare and other insurance COB information utilizing the Medicare verification...

  • Google Account Appeal Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NovanoxPH Full time

    Job DescriptionWe are looking for a Google Account Appeal Specialist to manage active Google Ads accounts with ongoing spend and running campaigns. The role involves resolving account issues by submitting appeals to bring accounts back to full functionality. Appeals may address various issues, including circumventing, compromised accounts, business operator...

  • Debt Recovery Specialist

    3 days ago

    Manila, National Capital Region, Philippines PHILMETAL PRODUCTS, Inc. Full time

    Credit and Collections ExpertWe are seeking a Debt Recovery Specialist to join our team at PHILMETAL PRODUCTS, Inc. in Makati City Metro Manila. The successful candidate will be responsible for managing the company's debt recovery and ensuring its financial health and stability.Key Responsibilities:Develop and implement effective debt recovery strategies to...

  • Nursing Appeal Coordinator

    5 days ago

    Manila, National Capital Region, Philippines Omega Healthcare Management Services Inc. Full time

    Role SummaryA Clinical Appeals Nurse Specialist is needed to work with our team at Omega Healthcare Management Services Inc., responsible for reviewing denied insurance claims, identifying the root cause of denials, and composing appeal letters to secure proper reimbursement.Main ResponsibilitiesReview claim and billing history to isolate any denials related...

  • Clinical Appeals Professional

    5 days ago

    Manila, National Capital Region, Philippines Omega Healthcare Management Services Inc. Full time

    Job DescriptionA Clinical Appeals Nurse Specialist is responsible for reviewing denied insurance claims, identifying the root cause of denials, and composing appeal letters to secure proper reimbursement.ResponsibilitiesAccess account from appropriate work queue and mark account worked to ensure it will not be assigned to another reviewer.Review claim and...

  • Service Recovery Specialist

    5 days ago

    Manila, National Capital Region, Philippines Conduent Full time

    Service Recovery Specialist:We are seeking a highly skilled and detail-oriented Service Recovery Specialist to join our team at Conduent. The successful candidate will be responsible for recovering outstanding customer accounts by making outbound calls to clients and resolving disputes in a professional and courteous manner.About the Role:The ideal candidate...

  • Backup and Recovery Specialist

    6 days ago

    Manila, National Capital Region, Philippines Network Management LLC Full time

    Network Management LLC National Capital Region, Philippines1 week ago Be among the first 25 applicantsGet AI-powered advice on this job and more exclusive features.Responsibilities:Perform daily monitoring and management of backup environments.Troubleshoot and resolve backup-related issues.Create and update documentation for backup processes.Provide 24/7 IT...

  • Google Ads Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NovanoxPH Full time

    About the Role:We are looking for a skilled Google Ads Specialist to join our team. If you have hands-on experience in creating and managing multiple Google Ads accounts, running warming campaigns, and appealing suspended accounts, we want you on boardResponsibilities:Google Account Warming Assistant – Create and manage multiple Google Ads accounts,...

  • Disaster Recovery Specialist

    6 days ago

    Manila, National Capital Region, Philippines St. Luke's Medical Center Full time

    Job DescriptionThe Risk Specialist for Business Continuity Management (BCM) is responsible for assisting the Associate Director in ensuring business recovery, restoration, and resumption plans are in place. This involves supporting the organization's response to disaster recovery events and other incidents that trigger BCM processes.Main...

  • Customer Recovery Expert

    4 days ago

    Manila, National Capital Region, Philippines Consistent Frozen Solutions Corporation Full time

    EARN YOUR SPOT AS A CUSTOMER RECOVERY EXPERTAs a Customer Recovery Expert at Consistent Frozen Solutions Corporation, you will play a crucial role in collecting outstanding payments from customers.Key Accountabilities:Contact customers to discuss outstanding payments and resolve any issues in a professional manner.Maintain accurate records of all...

  • Clinical Appeals Coordinator

    6 days ago

    Manila, National Capital Region, Philippines UST Full time

    About the RoleIn this critical position, you will work closely with our team to provide exceptional customer support, manage complex appeals and grievances, and ensure high-quality outcomes. Your strong analytical and problem-solving skills will enable you to navigate intricate cases and make informed decisions.This is an excellent opportunity to utilize...

  • Reconciliation Specialist

    6 days ago

    Manila, National Capital Region, Philippines InLife Health Care Full time

    JOB PURPOSE:This role is responsible for processing reconciliation requests from accredited providers distributed by the PPM-AM. Responds to the queries and provides updates on the status of claims in a timely manner. Ensure active status and be able to secure Certificate of Good Credit Standing from the facility/institution.PRINCIPAL ACCOUNTABILITIES:Claims...

  • Google Ads Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NovanoxPH Full time

    About the Role:We are looking for a skilled Google Ads Specialist to join our team. If you have hands-on experience in creating and managing multiple Google Ads accounts, running warming campaigns, and appealing suspended accounts, we want you on boardResponsibilities:Google Account Warming Assistant – Create and manage multiple Google Ads accounts,...

  • Resilience and Recovery Lead

    5 days ago

    Manila, National Capital Region, Philippines St. Luke's Medical Center Full time

    About the TeamThe Resilience and Recovery Lead will play a key role in developing and implementing resilience and recovery strategies for our organization. This position requires a strong background in Business Continuity Management and resilience principles.Key ResponsibilitiesDevelop and implement resilience and recovery strategies to ensure minimal...

  • Bookkeeping and Reconciliation Specialist

    6 days ago

    Manila, National Capital Region, Philippines GOOD 100 CONSULTANCY, INC. Full time

    Job OverviewGBC Consulting is seeking a skilled Bookkeeping and Reconciliation Specialist to join our team.The successful candidate will be responsible for managing expense reports and reimbursements, as well as entering financial transactions into our internal databases.They will also reconcile invoices and ensure the accuracy of all financial records.Key...

  • Disaster Recovery Manager

    6 days ago

    Manila, National Capital Region, Philippines AIA (Web) Full time

    AIA (Web) is a global leader in the insurance industry and we are currently seeking an experienced Disaster Recovery Manager to join our team.The ideal candidate will have a strong background in disaster recovery and business continuity planning and be able to develop and implement effective strategies to minimize disruption in the event of a disaster.Job...

  • Disaster Recovery and Resumption Expert

    5 days ago

    Manila, National Capital Region, Philippines St. Luke's Medical Center Full time

    About the RoleThe Disaster Recovery and Resumption Expert will play a crucial role in ensuring that our organization can quickly respond to business interruptions. This position requires a strong background in Business Continuity Management and disaster recovery processes.Key ResponsibilitiesDevelop and implement disaster recovery plans to ensure minimal...

  • Insurance Recoveries Manager

    4 days ago

    Manila, National Capital Region, Philippines TakeCare Asia Philippines, Inc. Full time

    Job SummaryWe are seeking a highly skilled Insurance Recoveries Manager to join our team at TakeCare Asia Philippines, Inc. The successful candidate will be responsible for managing insurance recoveries and ensuring that our company receives the payments it is owed.Key Responsibilities:Prepares documentation on member records in FACETS/Claimscape regarding...

  • 401k Reconciliation Specialist

    2 days ago

    Manila, National Capital Region, Philippines DOXA Talent Full time

    About the RoleThe 401k Reconciliation Specialist will be responsible for reconciling plan assets, performing annual 401(k) plan testing, calculating employee eligibility, preparing annual reports, and 5500 filings.Key Responsibilities:Work with clients to obtain the necessary information to prepare the annual reporting.Review documents submitted by clients...