CareFirst Careers

Senior Audit and Recoupment Specialist

Resp & Qualifications

Under the supervision of the Audit and Recoupment Supervisor, the incumbent’s accountabilities include, but are not limited to, the following:

Requests, receives, reviews and documents refunds of unsolicited or solicited checks from members, providers (professional, institutional or dental) or internal sources then applies the applicable overpayment strategies and procedures after research of medical and benefit policies to verify accuracy.  Performs the adjustment as needed to reflect the refund received.  Documents the appropriate inquiry tracking system with detailed reasons for the return of monies.  Records the transactions on the appropriate financial system so that ledger balances are appropriately decreased and financial reporting is accurate. Distributes and follows up on written correspondence to providers and policyholders in order to recoup overpaid claims and/or negotiate repayment agreements when necessary. 

Provides training in all aspects of the job to the Entry level position.  Conducts quality on the entry level position.  Analyzes trends and researches processes to update current SOPs.  Leads the unit in the absence of leadership.  Faciliate training and meetings as needed both one on one and in groups to departmental associates as well as those outside the area regarding job functionality, eRics system and other processes. 

Receives and reviews correspondence/phone inquiries from providers or members in regards to refund requests.  Researches the situation and answers accordingly with detailed explanations and/or additional requested information such as copies of cashed checks, EOBs, NOPs.  Accepts transfer calls from Provider or Member Service areas to discuss refund request with provider and member and work accordingly with the provider and member for repayment of the overpaid claims.  Documents the appropriate inquiry tracking system with the information then distributes written correspondence to providers and policyholders in order to recoup overpaid claims and/or negotiate repayment agreements when necessary.    Receives, reviews and verifies recoupment requests from various internal sources which have identified overpayments made to non-participating providers (professional, institutional or dental) or policyholders.

Returns refunds and transfers monies within the appropriate financial system that were sent to CareFirst in error after verification through research of medical or benefit policies. Ensures that Finance and Accounting Services are notified and accordingly to ensure financial reporting is accurate. Responds to service inquiries in order to resolve problems and ensure customer satisfaction. Works directly with multiple internal contacts via phone and email.  Provides phone support to the Member Services area on a contingency basis.


Required:  High school diploma, 5 plus years of claims processing and claims adjustment experience, ability to use basic P.C. tools.  Experience with claims processing and adjustment with FLEXX, Care, or other applicable systems/platforms are required.


  • Excellent knowledge of claims processing, Medical Policy, contractual benefits, and contractual provisions for both Indemnity Base Business and HMO claims.
  • Take out completely as none of these systems are valid.  Insert: Above average expertise with RICS, IACS, FEP Direct and other systems.
  • Above Average P.C. skills, and the knowledge of applications such as Microsoft Word, Excel, Access, and Windows NT.
  • Self-motivation, personal inquisitiveness, and the desire to use all available methods to find and recover overpaid dollars.

Preferred: 2-4 years college experience, and/or 5 years customer service experience and 2-3 years specific FEP A&R and FEP adjustment experience.


Department: Small Medium Service Business Unit BCBS Audit and Recoupment

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 7/20/2018

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.

The employee is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The employee must frequently talk and hear.  Weights of up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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