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Job Summary

The Payment & Refund Control Specialist is responsible for daily validation of multiple claims payment cycles, which includes accurate, efficient and timely end-to-end processing of claims refunds and stop payment requests. The payment activities include, but are not limited to, timely balancing and verifying payment data (daily and monthly adjudication controls to check register), evaluating the results of claim adjustment transaction on payments, assisting with problem resolution with the appropriate information systems staff, and communication of same to various operational areas

Requirements

EDUCATION

High School diploma or equivalent.

EXPERIENCE
Minimum one (1) year recent bookkeeping or account receivable experience.

Microsoft Excel experience required.
Claims processing or claims adjustment experience preferred.

*THIS IS IN-OFFICE 5 DAYS A WEEK*

ESSENTIAL SKILLS & ABILITIES
Account Receivable
Multitasking
Logical Thinking
Mathematics
Problem Solving
Customer Service
Oral & Written Communication
Strong Interpersonal Communication
Analyze Information
Professional Judgment
Highly Organized
Detail Oriented
Time Management
Confidentiality

Highly Motivated Self-Starter

Microsoft Office Suites including Excel & Word

Proficiency using computer applications, which includes spreadsheets, word processing, and database applications.
Ability to Work Independently or as a Team.

Skills

• Analyze Information • Customer Service • Evaluating Information • Interpersonal Communication • Microsoft Office • Multitasking • Oral Communications • Personal Organization • Sound Judgment • Time Management • Written Communication

Responsibilities

• Assists in other duties, as assigned • Coordinates the overpayment correspondence function, which includes the creation and delivery of Check Control memos in a timely manner. Initiates systematic releases of payment materials to print and mail operations. • Interprets and adheres to all regulations and policies related to overpayments to ensure compliance. This may vary depending on reason, type of claim overpayment and line of business. • Maintains awareness of corporate fiscal policy and fiscal administration guidelines and the impact on financial reporting of the Enterprise. • Performs daily validation of multiple claims payment cycles, which includes accurate, efficient and timely end-to-end processing of claims refunds and stop payment requests in accordance to corporate policies, audit requirements, and operational procedures and standards. Checks returned by providers or members and undeliverable checks must be controlled and disposed timely. • Works closely with Claims and Customer Service Operations, providers, and occasionally members to resolve problems and respond to inquiries regarding payments and refunds.

Certifications

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.