Recovery Audit Analyst I

Recovery Audit Analyst I

The Recovery Audit Analyst I is responsible for tracking and processing claim overpayments. This role supports the financial integrity of the organization by ensuring accurate application of claim offsets, posting of provider refunds, and reconciliation of recovered funds. The analyst manages voluntary and involuntary recovery activities, monitors demand letters, and collaborates with internal finance teams and external recovery vendors to ensure timely and accurate recovery of overpaid claim dollars in accordance with contractual, regulatory, and CMS requirements.

Key Responsibilities

• Apply claim offsets and adjustments related to identified overpayments across multiple lines of business.
• Post provider refund checks and electronic payments to corresponding claims accurately and timely.
• Process voluntary refunds received from providers, ensuring proper allocation and reconciliation to impacted claims.
• Review, track, and manage recovery demand letters issued to providers regarding identified overpayments.
• Responds to provider overpayment disputes.

Recovery & Financial Reconciliation

• Identify, validate, and document overpayment recoveries in accordance with internal policies and contractual requirements.
• Reconcile recovered amounts against claims system data to ensure accuracy in financial reporting.
• Monitor outstanding recoveries and follow up on unpaid or partially paid recovery requests.
• Ensure proper classification of recovered, canceled, and outstanding overpayment amounts.

Vendor & External Coordination

• Work collaboratively with external recovery vendors to support identification and recovery of overpaid claims.
• Review vendor-generated recovery findings for accuracy and compliance with health plan policies.
• Track recovery outcomes and ensure vendor performance aligns with contractual expectations.
• Communicate effectively with vendors to resolve discrepancies or missing documentation.

Finance & Reporting

• Prepare and submit reports to Finance detailing:
  • Identified overpayments
  • Cancelled recovery cases
  • Successfully recovered funds
  • Outstanding recovery balances
• Support monthly, quarterly, and annual financial reconciliation activities.
• Assist in audit preparation by providing detailed recovery documentation and supporting evidence.

Claims System & Data Management

• Accurately update claims systems to reflect recovery activity, including offsets, refunds, and adjustments.
• Maintain detailed records of recovery actions, correspondence, and financial transactions.
• Ensure consistency between claims, recovery systems, and financial reporting tools.
• Research claims history to validate recovery accuracy and resolve discrepancies.

Compliance & Regulatory Requirements

• Ensure all recovery activities comply with CMS guidelines, contractual obligations, and internal policies.
• Maintain adherence to HIPAA and information security standards when handling member and provider data.
• Support audit readiness by maintaining accurate and complete recovery documentation.
• Escalate potential compliance or financial risks to appropriate leadership.

Communication & Collaboration

• Collaborate with Claims Operations, Finance, Provider Relations, and Compliance teams to resolve recovery issues.
• Communicate professionally with providers regarding refund requests and recovery determinations when required.
• Support internal stakeholders with recovery-related inquiries and reporting needs.
• Participate in cross-functional initiatives to improve recovery processes and reduce overpayment occurrence.

Qualifications and Education

Minimum Qualifications

• High School Diploma or GED required.
• Minimum of 24 years of experience in healthcare claims, recovery, billing, finance, or managed care operations.
• Experience with claims processing systems and financial reconciliation activities.
• Understanding of healthcare claims payment and adjustment processes.

Preferred Qualifications

• Experience in a managed care or Medicare Advantage environment.
• Familiarity with recovery audit processes, overpayment identification, or payment integrity operations.
• Knowledge of provider refund processing and claims offset methodologies.
• Experience working with external recovery vendors or audit firms.

Skills & Competencies

• Strong analytical and reconciliation skills
• High attention to detail and financial accuracy
• Ability to manage multiple recovery cases simultaneously
• Strong documentation and reporting skills
• Effective communication and collaboration abilities
• Problem-solving skills with a focus on root cause identification
• Ability to work independently in a production-driven environment

Working Conditions

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.
• Works in the field
• Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period. The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Performance Measurements

• Duties accomplished at the end of the day/month.
• Attendance/punctuality.
• Compliance with Company regulations.
• Safety and Security.
• Quality of work.

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Employee Acknowledgement:

I have read this job description and understand what is expected of me while I occupy this role.