Description
COORDINATION OF BENEFITS SPECIALIST
Duration: 6-month contract (W2)
Location: Rockville, MD 20852
Job Number: 59119
Client: One of the country's largest health care and health plan provider
Standard Hours: M-F 7:30am - 4:00pm or 8:00am - 4:30pm
Job Description:
- Identifies, researches, and validates cases involving Medicare, other commercial carrier, dual coverage, and other third party
- Liability situations, including researching primacy determination on complex cases involving another payor, claims cost avoidance
Essential Functions:
- Distributes eligibility surveys to appropriate members for the entire membership database
- Places primary calls to members for the entire membership database when surveys aren't returned
- Applies National Association of Insurance Commission (NAIC) guidelines to determine primary/secondary liabilities when required
- Applies Medicare Secondary Payor & NAIC rules and regulations to determine Medicare and Commercial Primacy determination for accurate payment of benefits relative to claims adjudication and billing
- Generates and analyzes applicable departmental reports, documents revenue recovery opportunities from providers, attorneys and other insurance adjusters, etc., and communicates to Claims Administration
- Reviews and responds to various forms of inquiries from CMS, providers, members, attorneys, and other insurance personnel
- Manages Macess workflow queues according to claims department policies, guidelines, and turn-around time
- Assists in the development and implementation of policies and procedures for the department and COB unit. Recommend changes to management
- Interprets new laws and regulations in all operating jurisdictions including CMS, NAIC, and federal and state. Communicates changes in regulations appropriately to all interested parties. Advise management of pending changes
- Maintains current knowledge of:
- Covered and non-covered Medicare benefits administration and Health Plan benefits
- Specific provider contractual arrangements
- Provider Service Center processes and procedures
- Appeals process
- Changes in Claims processing policies and procedures
- Acts in the capacity of Medicare and commercial COB subject matter specialist to several internal departments and external customers/clients
- Provides linkages between the departments to facilitate recovery, billing, and other primacy related issues
- Maintains monthly reports on liens, Third Party and Workers Compensation questionnaires, recoupment revenue, adjustments, and other related activities
- Performs retroactive claims payment audit for newly identified Medicare and Commercial primary members. Communicates recovery opportunities to Claims Administration
- Maintains Medicare and Commercial primacy determinations in TPL module, HSD Diamond, and PFS Billing system
Basic Qualifications:
- Bachelor's degree or the equivalent relevant years' relevant work experience required
- 4 years' experience specializing in COB, Medicare, Medicaid, Dual Coverage TPL and/or Workers Compensation claims
- Demonstrated experience in health insurance claims processing and benefits environment. Working knowledge of Medicare, medical and other insurance terminology
- Experience with computer applications and other PC-based skills
- Demonstrated expertise in industry practices and regulations in the tri-state area pertaining to Medicare, Workers Compensation, Dual Coverage, and Subrogation
- Demonstrated excellent communication skills: writing, verbal & negotiating skills
- Knowledge of Medicare and other insurance products
- Demonstrated writing and reporting skills
Preferred Qualifications:
- 1 year in a customer service environment preferred
- Experience working with cross-functional teams preferred