Lead, Medicare Payments Recovery
Title: Lead, Medicare Payments Recovery
Location: Remote (United States)
Department: Product - Member Data
Job Description:
Position Summary
This role supports a highly specialized Medicare Secondary Payer (MSP) recovery function focused on identifying and resolving incorrect CMS/Medicare payment cases. This role performs detailed, manual case review to validate coverage responsibility, identify overpayments, and drive recovery efforts with impacted plans. Due to CMS data access and extraction limitations, the work is highly analytical and manual in nature, requiring strong judgment, documentation rigor, and deep familiarity with benefits coordination and claims recovery processes.
Specific Responsibilities
Medicare Secondary Payer (MSP) & Claims Recovery
• Identify cases where Medicare was incorrectly designated as the primary payer.
• Perform detailed, manual review of member eligibility, coverage timelines, and payment responsibility to validate recovery opportunities.
• Support recovery of Medicare overpayments by coordinating accurate case documentation and tracking recovery status through resolution.
• Analyze membership, billing, and CMS-related data to support payment integrity outcomes.
Compliance, Documentation, & Outcome Reporting
• Maintain a detailed, auditable list of all members and cases reviewed.
• Track and report recovery activity.
• Provide regular updates and maintain clear documentation for each active engagement to support transparency and leadership visibility into client progress and outcomes.
• Ensure work meets audit and compliance requirements.
• Maintain high standards of documentation accuracy and traceability given the financial and regulatory sensitivity of the work.
• Develop and maintain detailed written process documentation to support training of additional resources and ensure long-term sustainability of the function.
Forecasting & Capacity Planning
• Deliver a written monthly forecast outlining anticipated case volume and expected recovery outputs.
• Support leadership planning by providing insight into recovery trends, case complexity, and capacity constraints.
• Participate in client-facing meetings and communications as needed.
Skills
• Strong analytical skills with the ability to perform detailed, manual case review
• Claims and billing data analysis
• Revenue tracking and reporting
• Process documentation and workflow design
• Stakeholder coordination and client communication
• High attention to detail
• Ability to track, report, and reconcile member and revenue data
• Strong written communication and documentation skills
Experience
• Experience producing structured, auditable documentation and reports
• Experience working in healthcare data, revenue operations, or regulatory validation environments
• Demonstrated experience working with complex eligibility, coverage, and payment data
• Comfort working in highly governed environments and familiarity with healthcare compliance and audit standards
• Experience in Medicare Secondary Payer (MSP), payment integrity, benefits coordination, or claims recovery
• Experience with CMS data, Medicare recovery processes, or healthcare overpayment recovery
• Background in payment integrity, revenue recovery, or benefits administration
Who We Are
CAQH is the trusted data connector at the core of healthcare. For more than 25 years, we have powered the industry with the largest and most complete healthcare data foundation in the U.S., including more than 4.8 million provider data records sourced directly from providers and member data representing 75% of covered lives supplied by health plans. By improving how essential information flows across the system, CAQH helps healthcare operate more efficiently, accurately, and with greater confidence.
What You Get
At CAQH, you will do meaningful work at the intersection of healthcare, data, and technology, helping solve complex problems that make the healthcare system work better. You will collaborate with experienced professionals who care deeply about accuracy, trust, and meaningful impact in a fully remote environment.
CAQH offers competitive compensation and a comprehensive benefits package for full-time employees, including medical, dental, and vision coverage, a 401(k) with company contributions and matching, paid parental leave, tuition assistance, and generous paid time off. We are committed to investing in our people and supporting professional growth over time.
Equal Opportunity Employer
CAQH is proud to be an equal opportunity employer and is committed to fostering a workplace where all individuals are valued, respected, and empowered.
Employment decisions at CAQH are made without regard to race, color, religion, sex, national origin or ancestry, age, marital status, disability, protected veteran status, personal appearance, sexual orientation, gender identity or expression, familial status, family responsibilities, matriculation, political affiliation, genetic information, source of income, place of residence, or any other characteristic protected by law. CAQH does not tolerate unlawful discrimination or harassment of any kind.
Applicants have rights under the Family and Medical Leave Act (FMLA), Equal Employment Opportunity (EEO), and the Employee Polygraph Protection Act (EPPA). If you need a reasonable accommodation to apply for a posted position, please contact the CAQH People & Culture team at [email protected] or 202-517-0436.
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Location: Remote (United States)
Department: Product - Member Data
Job Description:
Position Summary
This role supports a highly specialized Medicare Secondary Payer (MSP) recovery function focused on identifying and resolving incorrect CMS/Medicare payment cases. This role performs detailed, manual case review to validate coverage responsibility, identify overpayments, and drive recovery efforts with impacted plans. Due to CMS data access and extraction limitations, the work is highly analytical and manual in nature, requiring strong judgment, documentation rigor, and deep familiarity with benefits coordination and claims recovery processes.
Specific Responsibilities
Medicare Secondary Payer (MSP) & Claims Recovery
• Identify cases where Medicare was incorrectly designated as the primary payer.
• Perform detailed, manual review of member eligibility, coverage timelines, and payment responsibility to validate recovery opportunities.
• Support recovery of Medicare overpayments by coordinating accurate case documentation and tracking recovery status through resolution.
• Analyze membership, billing, and CMS-related data to support payment integrity outcomes.
Compliance, Documentation, & Outcome Reporting
• Maintain a detailed, auditable list of all members and cases reviewed.
• Track and report recovery activity.
• Provide regular updates and maintain clear documentation for each active engagement to support transparency and leadership visibility into client progress and outcomes.
• Ensure work meets audit and compliance requirements.
• Maintain high standards of documentation accuracy and traceability given the financial and regulatory sensitivity of the work.
• Develop and maintain detailed written process documentation to support training of additional resources and ensure long-term sustainability of the function.
Forecasting & Capacity Planning
• Deliver a written monthly forecast outlining anticipated case volume and expected recovery outputs.
• Support leadership planning by providing insight into recovery trends, case complexity, and capacity constraints.
• Participate in client-facing meetings and communications as needed.
Skills
• Strong analytical skills with the ability to perform detailed, manual case review
• Claims and billing data analysis
• Revenue tracking and reporting
• Process documentation and workflow design
• Stakeholder coordination and client communication
• High attention to detail
• Ability to track, report, and reconcile member and revenue data
• Strong written communication and documentation skills
Experience
• Experience producing structured, auditable documentation and reports
• Experience working in healthcare data, revenue operations, or regulatory validation environments
• Demonstrated experience working with complex eligibility, coverage, and payment data
• Comfort working in highly governed environments and familiarity with healthcare compliance and audit standards
• Experience in Medicare Secondary Payer (MSP), payment integrity, benefits coordination, or claims recovery
• Experience with CMS data, Medicare recovery processes, or healthcare overpayment recovery
• Background in payment integrity, revenue recovery, or benefits administration
Who We Are
CAQH is the trusted data connector at the core of healthcare. For more than 25 years, we have powered the industry with the largest and most complete healthcare data foundation in the U.S., including more than 4.8 million provider data records sourced directly from providers and member data representing 75% of covered lives supplied by health plans. By improving how essential information flows across the system, CAQH helps healthcare operate more efficiently, accurately, and with greater confidence.
What You Get
At CAQH, you will do meaningful work at the intersection of healthcare, data, and technology, helping solve complex problems that make the healthcare system work better. You will collaborate with experienced professionals who care deeply about accuracy, trust, and meaningful impact in a fully remote environment.
CAQH offers competitive compensation and a comprehensive benefits package for full-time employees, including medical, dental, and vision coverage, a 401(k) with company contributions and matching, paid parental leave, tuition assistance, and generous paid time off. We are committed to investing in our people and supporting professional growth over time.
Equal Opportunity Employer
CAQH is proud to be an equal opportunity employer and is committed to fostering a workplace where all individuals are valued, respected, and empowered.
Employment decisions at CAQH are made without regard to race, color, religion, sex, national origin or ancestry, age, marital status, disability, protected veteran status, personal appearance, sexual orientation, gender identity or expression, familial status, family responsibilities, matriculation, political affiliation, genetic information, source of income, place of residence, or any other characteristic protected by law. CAQH does not tolerate unlawful discrimination or harassment of any kind.
Applicants have rights under the Family and Medical Leave Act (FMLA), Equal Employment Opportunity (EEO), and the Employee Polygraph Protection Act (EPPA). If you need a reasonable accommodation to apply for a posted position, please contact the CAQH People & Culture team at [email protected] or 202-517-0436.
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