Third Party Liability/Coord Benefits Program Manager

Competitive Compensation & Benefits Package!  

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details. 

Office Location:  Remote Option; Available for Partners' NC locations (or within 40 miles of NC border)

Closing Date: Open Until Filled

Primary Purpose of Position: This position will oversee Partners’ development, implementation, revision, maintenance, and promotion of the company’s third-party liability (TPL)/coordination of benefits (COB) to assist in avoiding payments when other insurance resources are available to the member (cost avoidance); to recover funds from other insurance when Medicaid and State Funded claims were paid when other insurance should have been (retrospective recovery); to perform subrogation recovery in the event a member is involved in an event subject to subrogation recovery (subrogation); and to work with vendors on TPL come-behind recovery.  

Role and Responsibilities:  

• Conduct, plan and perform...
• Conduct 
• Liaise with various Partners departments and team members to provide leadership in the development, implementation and maintenance of Partners’ identification, cost avoidance, subrogation and recovery of TPL/COB.
• Oversee Partners’ contractors that implement and perform TPL/COB cost avoidance, retrospective recovery and subrogation. 
• Consult with legal counsel to prepare testimony and other information necessary for appeals/grievances related to actions taken in connection with TPL/COB. 
• Work with Partners Information Technology (IT) teams to ensure that Partners’ and NC DHHS’ TPL/COB contractors receive the data necessary to ensure compliance with contract statements of work and ensure that Partners can produce NC DHHS required reports related to TPL/COB.
• Consult with IT to manage data and generate needed program reports.
• Attend meetings with Partners, vendors, NC DHHS and others as needed to ensure successful implementation and maintenance of the TPL/COB program.
• Work with NC DHHS’ TPL come-behind recovery contractor and ensure Partners’ compliance with program requirements.
• Work with Eligibility and Enrollment as needed to ensure that found insurance is added to members profiles and that information is in turn reported to NC DHHS.
• Work with Claims department to adjust, reverts, re-adjudicate claims associated with retrospective recovery of TPL/COB. Communicate changes related to said claims to providers.
• Ensure that Partners complies with all NC DHHS contract requirements around TPL/COB and stays abreast of contract changes.
• Prepares/oversees timely preparation of all NC DHHS required reports related to TPL/COB cost avoidance, retrospective recoveries, and subrogation. 
• Remain abreast of all federal and North Carolina laws, regulations, rules and policies applicable to TPL/COB.
• Develop, coordinate, and facilitate educational training to the Provider Network and agency personnel on issues relating to TPL/COB.
• Analyzes and develops standards of measurement for subsequent program review and represents the section manager by serving as liaison with State/federal legislative personnel, State agencies, and provider organizations.
• Present TPL/COB and/or compliance materials to educate stakeholders.
• Respond to audits and reviews of Partners TPL/COB/Subrogation program from state and federal teams auding Partners program compliance.
• Identify information system edits/alerts/reports in need of implementation to further Partners overall TPL/COB program.
• Recommend and implement compliance initiatives, policies, procedures, and practices designed to promote and encourage the prevention, reporting, and recovery of TPL/COB.
• Serve on and/or facilitate various agency committees as deemed necessary by the Claims Director.
• Develop and maintain Partners policies and procedures and manuals related to TPL/COB.
• Develop, implement, utilize, and assure adherence to standardized statistical sampling methodology.
• Use appropriate software and systems to complete work assignments.
• Perform other duties as assigned.

Knowledge, Skills and Abilities: 

• Strong knowledge of state and federal laws, including those related to Medicaid FWA, TPL/COB/Subrogation and regulatory compliance are required. 
• Knowledge of investigative methods and procedures.
• Knowledge of claims processing and clinical services.
• Excellent interpersonal and communication skills. 
• Excellent analytical skills.
• Effective time management and organizational skills.
• Excellent conflict management skills. 
• Proficient in Word, Excel, and Power Point. 
• Ability to learn and effectively manage various information systems including Partners’ claims reporting and North Carolina TRACKS.
• Ability to develop solutions and make recommendations for necessary process improvements. 
• Ability to interpret contractual agreements, business oriented statistics, clinical/administrative services and records.
• A high level of integrity and discretion is required to effectively carry out the responsibilities related to this position.

Education and Experience Required: Bachelor’s Degree in a Human Services field, Health Administration, health informatics/analytics, compliance, analytics, government/public administration, auditing, prelaw, criminal justice or related field. Minimum of three years recent experience in MH/DD/SA, with compliance monitoring, auditing or investigation experience. 

Education and Experience Preferred: Five years recent experience in MH/DD/SA, experience analyzing complex data, claims processing, utilization reviews, provider credentialing/monitoring, and/or fraud and abuse detection. Preferred credentials: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), and/or certified as an investigator/inspector through the Council on Licensure, Enforcement, and Regulation (CLEAR). Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) certification. Experience with statistical sampling methods is desirable. 

Licensure/Certification Requirements: N/A