Coordination of Benefits Specialist

• Schedule: Mon – Fri  8:00am – 4:30pm CST
• 100% Remote Opportunity
• Potential Flexible Schedule

What will YOU be doing for us?  Responsible for managing and leveraging other insurance coverage information or leads provided through various sources, to include; referrals and reports from providers, subscribers, clients, state agencies or any health plan entity for the purpose of establishing an order benefits determination to ensure accurate application of benefits in claims adjudication. 

What will YOU be working on every day?

• Comprehensive knowledge of primary payer Explanation of Benefits (EOB); submitted amounts, billing codes, maximum approved fees, contractual adjustments, allowed amounts, co-pays, payment, patient responsibility and remarks codes in efforts to interpret and input the data accurately for processing and adjudication. 
• Ability to understand and apply another carrier’s benefits, to include allowed vs. paid amount, non-covered services, etc. in the claims adjudicated by SKYGEN ensuring the maximum allowable benefits are provided and not exceeded. 
• Responsible for ensuring departmental tasks are completed in order to meet client turnaround times for claim payment across multiple lines of business.
• Manages all special COB handling requests to support both internal and external requirements.
• Act as a main point of contact and subject matter expert for receiving and resolving complex internal and external requests and support various assigned tasks and initiatives as directed by the Specialty Processing Leadership Team.
• Act as a subject matter expert for items related to COB by answering questions to internal and external contacts and resolving matters that may fall outside of the established workflows. This includes third party vendors, data transmissions or consultants.
• Assist in developing documentation, training materials and/or programs for internal departments.
• Comprehensive knowledge of various types of form submissions, and having the skillset to process and respond to questions received by the team or internal departments based not only the form type and various field requirements, but also by the client specific requirements within client turnaround times.  Various types of form submissions are, but not limited to:  
  • American Dental Association (ADA) forms
  • CMS-1500 Physician Claims forms
  • UB-04 Facility Claim form
  • Member Reimbursement forms
• Maintains comprehensive knowledge of different processing rules and requirements as it relates to different lines of business serviced by the company.  Ability to differentiate various forms, field and client requirements by line of business and to multitask within different modules of the Enterprise System efficiently and accurately with entering required data.  Lines of business are:
  • Government Dental - Medicare/Medicare
  • Commercial
  • Medical – Medicare/Medicaid
  • Vision
• Collaborate with internal departments (Enrollment) for reviewing and updating of member’s enrollment records to reflect accurate primary insurance information. 
• Perform outreach to the member’s primary insurance company or client market to verify and record benefits for accurate processing and payment through SKYGEN.   
• Responsible for recording within the Enterprise system the members other coverage information provided on claim submissions.   
• Log unclean submissions to prompt the generation of rejection letters back to the servicing provider.   
• Update existing resources used to maintain current knowledge and understanding of COB processing.   
• Regularly partner with company’s System Architect to problem-solve complex tasks related to COB processing issues. Provide innovation for resolution and/or new procedures. Works with Manager to ensure that solutions are within department budget goals of reducing expenses.   
• Coordinate ancillary Orthodontic cases submitted for accurate COB processing.
• Manages daily work volumes to ensure client turnaround times are met. 
• Identify trends and suggest and develop an action plan for correction as it relates to provider submissions errors.  Collaborate with internal teams if required for provider outreach and education.
• Resolve provider data discrepancies submitted that prevents the submission to proceed through the system. Utilizing both external databases and our internal Provider Services team to validate provider credentials. 
• Assist with training support of internal team members.

Additional Responsibilities:

• Develop and communicate to management ways to improve policies and procedures and workflows to maximize efficiency.
• Coordinate any internal meetings related to, new client requirements or changes in processing rules with appropriate internal staff.
• Assist with special projects requests assigned by leadership team. 

What qualifications do YOU need to have to be GOOD candidate?

• Required Level of Education, Licenses, and/or Certificates
  • High school diploma or equivalent

• Required Level of Experience
  • 2+ years of experience with Coordination of Benefits in insurance or insurance billing.

• Required Knowledge, Skills, and Abilities
  • Comprehensive knowledge of various types of COB submissions and processing rules
  • Familiarity with American Dental Association (ADA) forms, CMS-1500 Physician Claims form, UB-04 Facility Claim form or Member Reimbursement forms
  • Intermediate knowledge of Microsoft Office products
  • Knowledge of billing and diagnosis codes
  • Ability to work effectively with multiple interruptions
  • Demonstrated time management skills in order to meet deadlines
  • Excellent attention to detail and critical thinking skills
  • Ability to utilize resources to solve problems independently
  • Excellent written and verbal communications.
  • Ability to maintain objectivity in difficult situations.

What qualifications do YOU need to have to be a GREAT candidate?

• Preferred Level of Education, License, and/or Certificates
  • Postsecondary Education in a related field

• Preferred Level of Experience
  • 3+ years of related experience with Coordination of Benefits in insurance or insurance billing.
  • Previous experience as a Claims Intake Specialist or similar role
  • Previous experience in working with managed care
  • Previous experience in a training or project role

• Preferred Knowledge, Skills, and Abilities
  • SQL Server Reporting Services
  • Transact SQL
  • Software development tools (for example, Microsoft Visual Studio, Microsoft Team Foundation Server)
  • Familiarity with generally accepted accounting principals
  • Knowledge of the Enterprise or like system