Job description

The Coordinator of Benefits Specialist is responsible for investigation, documentation, and processing of multiple types of insurance claims while meeting or exceeding designated production and quality standards. Conducts outbound calls to insurers to verify other coverage information provided to us by the member, CMS, or other entities. Document and maintain COB data in the source system. To successfully perform the role, the COB Specialist must have a comprehensive understanding of various regulations related to COB and subrogation and must complete all duties with strict regard to policies and procedures. Completes all duties with strict regard to policies and procedures set forth by the Enrollment Services Manager, Centers for Medicare and Medicaid Services (CMS), Pennsylvania Department of Welfare (DPW), and Pennsylvania Insurance Department (PID). Responsible for responding to internal customer inquiries and resolving issues to meet or exceed customer requirements. In addition, the Coordination of Benefits Specialist, should maintain a high level of interaction with the other internal departments.

This position follows a hybrid work structure, with the majority of work conducted remotely. Candidates must be available to report to the office as needed.

Responsibilities:

Provides support with departmental mailboxes, web requests, and/or chats. Consistently demonstrates courteousness and professionalism with internal and external customers. Anticipates and addresses additional questions and concerns.
Ability to interpret and apply complex regulations as mandated by CMS, DPW, and PID as related to coordination of benefits, subrogation, and Medicare.
Properly updates member records to reflect primary or secondary coverage based on findings. Ensures documentation is accurate, clear, and thorough.
Consistently meets departmental quality standards
Consistently meets departmental production standards
Investigate all possible instances of other insurance for all lines of business appropriately and accurately utilizing internal and external systems to verify the existence of other insurance. Appropriately and accurately applies NAIC, Medicare, and other state and/or federal regulations to determine the proper order of benefits.
Accurately recognizes and reports trends or issues identified from daily work and works in partnership with leadership to develop and implement solutions.
Demonstrates strong knowledge of claims processing and ensures claims and associated holds impacted by other insurance are properly researched and resolved in a timely fashion. Recognizes and takes action to ensure timely reprocessing of claim(s).
Identify areas of opportunity to improve service to members and/or reduce member impact. Initiate outreach efforts, to members, other carriers, or clients, when deemed appropriate or necessary to gather the necessary information to resolve issues or appropriate resolve cases.
Identifies updates required to external systems, state or federal, and takes action to ensure the appropriate and accurate update is made on time. Reviews and works any submission rejection on time and consistently meets departmental goals related to submission acceptance.
Interface with internal and external customers to ensure resolution of inquiries and concerns. Access, investigate, and resolve issues to achieve customer satisfaction, seeking to achieve one-touch resolution with all departmental requests for assistance.
Process member requests to update other insurance coverage, including surveys, phone calls, custody court order requests, or other member correspondence. Ensures request is fully processed, documented, and resolved.
High school diploma or equivalent required; college degree preferred.
1 year of customer service experience and or other business environment.
Ability to interpret and apply complex regulations as mandated by CMS, DPW, and PID as related to coordination of benefits, subrogation, and Medicare.
Strong organizational, interpersonal, leadership, and communication skills.
Attention to detail is critical to the success of this position, with skills in customer orientation.
Will need to manage multiple tasks and projects. Strong analytical skills are required.
MS Office/PC skills required.