Director of Retrospective Recovery - ClaimInsight

Job Description

Job Description

Description:

About AMPS:

At AMPS, we are transforming healthcare cost containment through innovative analytics, data-driven insights, and a deep commitment to fairness and transparency. ClaimInsight, one of our core solutions, specializes in retrospective (retro) claim reviews and payment recovery for self-funded employers, TPAs, and health plans. We’re on a mission to help clients maximize savings while maintaining strong provider relationships.

Position Overview:

As the Director of Retrospective Recovery for ClaimInsight at AMPS, you will be responsible for overseeing the entire process of recovering healthcare claim overpayments in collaboration with third-party administrators (TPAs), provider networks, and other business partners. This role involves managing operations, building relationships with partners, leading the recovery team, and optimizing processes to achieve successful recovery outcomes.

You will play a crucial role in ensuring the recovery process from start to finish is successful, clients can obtain the appropriate funds, and that compliance and client satisfaction are upheld.

Key Responsibilities:

• Lead and manage retro recovery workflows across various B2B partner channels (TPAs, Providers, networks).
  • This includes the build-out of workflows, processes, and tools for a new team.
• Collaborate with internal teams (Data Analytics, Retrospective Review Team, Legal, Client Services, IT) to ensure successful case resolution and recoveries. This person will take a lead role in ensuring IT priorities are appropriate when it comes to building this practice.
• Engage with external B2B partners to negotiate and communicate recovery positions professionally and effectively. Deep dive into process details while maintaining the greater picture and leading the department to successful outcomes.
• Track, report, and optimize recovery performance using ClaimInsight tools and dashboards; ensure processes and workflows are using the latest and greatest insights for working with bad/old data, incorrect addresses, etc., based on industry knowledge and previous experience.
• Ensure compliance with applicable laws, client agreements, and industry regulations (ERISA, HIPAA, CAA).
• Develop playbooks, SOPs, and training materials for continuous improvement and scalability of the recovery process.
• Provide subject matter expertise to the client during onboarding , internal meetings, and cross-functional projects.

Qualifications:

• 10+ years of experience in healthcare claims, recovery, or payment integrity, preferably in a B2B environment.
• Deep understanding of medical claims processing, post-payment overpayment recovery , and provider negotiations.
  • Specific experience with recovering retrospective overpayments from providers is required.
• Experience working with TPAs, networks, providers, or healthcare payers .
• Excellent analytical skills with a data-driven mindset and comfort working with spreadsheets, reports, and BI tools.
• Strong interpersonal and negotiation skills ; able to influence both internal and external stakeholders.
• Ability to prioritize and manage multiple recovery projects in a fast-paced environment.
• Understanding of ERISA and CAA obligations, the Recovery Audit Contractor (RAC) program, and the retrospective payment system.
• Bachelor’s degree or equivalent work experience in healthcare, business, or related field.

Education and Experience:

· Bachelor's Degree Preferred

· Five or more years of experience in business analysis or a related field

Physical Requirements

· Indoor office environment with moderate noise

· Travel is required for on-site client visits approximately 10% of the time.

· Intermittent physical effort may include lifting to 25 lbs., walking, stopping, kneeling, crouching or crawling may be required

· Frequent sitting, use of a keyboard, reaching with hands and arms, talking and hearing approximately 70% of the time; 30% or less time is spent standing

· Normal vision abilities required, including close vision andthe ability to adjust focus