PacificSource Health Plans

  • Claims Audit and Overpayment Recovery Specialist

    Job Location US-OR-Eugene
    Job ID
    Regular Full-Time
    Hiring Pay Range
    # of Openings
  • Overview

    Perform random audits of processed claims and report on results to help identify training needs, and system or process issues. Review and research medical claims and determine coverage based on contract, provider status and claims processing guidelines. Accurately interpret benefit and policy provisions applicable to fully-insured group/individuals and self-funded clients. Responsible for identifying overpayments, preparing recovery requests, and performing follow-up tasks on outstanding overpayments. Provide customer service assistance to external customers regarding overpayment transactions.


    1. Review claims referred to the Audit team that require investigation for possible overpayment. Document the findings and determine the appropriate course of action.
    2. Generate appropriate refund request letters. Periodically follow-up by phone to assure timely recovery of monies owed to PacificSource. Document any applicable notes following team documentation standards.
    3. Accurately process requested and unrequested refunds by verifying the reason for the reimbursement, processing the refund and researching member history for other potential overpayments.
    4. Track, manage and report status of refund requests to Team Leader.
    5. Follow appropriate accounting procedures to reconcile refund amounts and generate reports as needed.
    6. Accurately adjudicate credit adjustments in Facets and assign the applicable adjustment reason code to the claim to facilitate future tracking and reporting.  
    7. Assign uncollected overpayments to collection agency.
    8. Perform random and problem-focused audit of claims by researching benefits, claim edits and claim policies and procedures, comparing to processed claim. Provide immediate feedback on claims with errors, notifying original claims analyst and team leader.
    9. Accurately resolve or reprocess claims to correct setup and/or system errors identified through multiple channels according to the instructions provided for the project.
    10. Work assigned reports to monitor and/or correct claims for specific processing reasons. May also assist in processing other specialty claims as workload or auditing requires.
    11. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    12. Provide customer service assistance to internal and external customers to answer questions and resolve refund issues.
    13. Document issues that affect claims processing quality and advise team leader of claims processing or system configuration concerns and/or problems.

     Supporting Responsibilities:

    1. Actively participate in department or inter-departmental workgroups. Share information or issues with department leaders.
    2. Regularly attend team meetings and daily team Visual Board huddle.
    3. Meet department and company performance and attendance expectations.
    4. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    5. Perform other duties as assigned.


    Work Experience: Minimum of two years PacificSource claims adjudication experience, or equivalent health insurance claims experience, with the demonstrated ability to take on increasingly complex claims processing roles within Facets Workflow. Experience with account collections and handling difficult customers is helpful.


    Education, Certificates, Licenses: Requires high school diploma or equivalent.


    Knowledge: Thorough understanding of PacificSource products, plan designs, provider/network relationships and health insurance terminology. Research skills and ability to evaluate claims in order to enter and process accurately. Preferred computer skills include keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to prioritize work and perform under time constraints with minimal direct supervision. Ability to communicate effectively with all types of customers. Ability to develop Lean training materials and deliver claims training to others. A fundamental understanding of self-insured business is helpful.



    Our Values

    • Adaptability
    • Building Customer Loyalty
    • Building Strategic Work Relationships
    • Building Trust
    • Continuous Improvement
    • Contributing to Team Success
    • Planning and Organizing
    • Work Standards
    • We are committed to doing the right thing.
    • We are one team working toward a common goal.
    • We are each responsible for our customers’ experience.
    • We practice open communication at all levels of the company to foster individual, team and company growth.
    • We actively participate in efforts to improve our communities-internal and external.
    • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.




    Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.


    Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.



    This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.


    PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.



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