Provides member outreach activities with some guidance. Serves as a liaison and resource for other coverage information (OCI) and coordination of benefits (COB) matters. Conducts research and resolution of termination and change requests for OCI. Contributes to determination and coverage updates to identify primary, secondary, and tertiary coverages. Independently records OCI/COB information and notes into necessary software. Provides production data analysis and some initial analysis to support reporting. Maintains comprehensive foundational knowledge of current laws, regulations, and departmental procedures. Applies operational policies throughout their work. Follows broad guidance to identify areas where claims are being coordinated incorrectly. Without significant guidance, investigates member coverage and/or claims/cases to determine outside payers benefits. Processes and/or assesses COB claim/cases under minimal supervision. Identifies claim/cases that are COB-related. Analyzes problem claims/cases, helping implement solutions, and follows up on their implementation. Coordinates and involves relevant stakeholders. Supports the resolution of escalated inquiries related to OCI. Supports audit processes.
Essential Responsibilities:
Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.
Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.
Assesses claims/cases in support of COB by: following broad guidance to identify areas where claims/cases are being coordinated incorrectly by reviewing information available from all sources; without significant guidance, investigating member coverage and/orclaims/cases to determine amount of outside payers benefits; under minimal supervision, contributing to processing/assessment of COB claims/cases for timely reimbursement; and, under minimal supervision, reviewing pending and finalized claims/cases to identify those that are COB-related.
Contributes to cross-group coordination by: with some guidance, providing member outreach activities, such as preparing and/or sending questionnaires to members and conducting outreach calls to other insurance carriers or members; serving as a liaison and resource using comprehensive foundational knowledge of other coverage information (OCI)/coordination of benefits (COB) for matters between the organization, members, and outside providers; conducting the research and resolution of termination and change requests for OCI, with some guidance; identifying training needs for key stakeholders throughout the organization, based on some direction; with some support, providing documentation of industry standards, Medicare guidelines, or other relevant materials for rendering decisions on medical policies or benefits; and contributing todetermination and coverage updates to identify primary, secondary, and tertiary coverages.
Documents and reports on COB processes by: independently recording OCI/COB information and notes to enter them into all necessary software programs, with periodic supervisor/manager review of work; NA providing production data and conducting some initial analysis in support of report development, based on broad guidelines; NA maintaining comprehensive foundational knowledge of new and existing case and/or administrative law, benefit administration throughout systems and departments, and changes to regulations and requirements; and incorporating and applying new and updated internal operational policies and procedures into their work.
Investigates inquiries and issues related to COB by: analyzing problem claims/cases and assisting with implementation of solutions; coordinating with and involving relevant stakeholders when researching and resolving issues; applying standard strategies when following up on implementation of recommendations; independently contributing to inquiries into covered spouse and dependent health coverage; using comprehensive foundational knowledge to support resolution of inquiries related to OCI; and supporting audit processes by coordinating with audit stakeholders and documenting the process and results.
Minimum Qualifications:
Minimum six (6) years of experience in Healthcare, Healthcare Operations, Insurance, Finance, or a directly related field OR Bachelors degree in Healthcare, Business, Insurance, Finance, Nursing, or related field AND minimum three (3) years of experience in Healthcare, Healthcare Operations, Insurance, Finance, or a directly related field.
Additional Requirements:
Knowledge, Skills, and Abilities (KSAs): Confidentiality; Member Service; Interpersonal Skills; Legal And Regulatory Requirements; Time Management; Adaptability; Autonomy; Organizational Skills; Microsoft Office