Coordination of Benefits Specialist - 6-Month Contract (57239)

COORDINATION OF BENEFITS SPECIALIST

DURATION: 6-month contract (W2)

LOCATION: Rockville, MD 20852

JOB NUMBER: 57239

CLIENT: One of the country's largest health care and health plan providers

STANDARD HOURS: 7:30 - 4 or 8:00 - 4:30

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 and 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, other insurance adjusters, etc., and communicates to Claims Administration
- Reviews and responds to various forms of inquiries from CMS, providers, members, attorneys, other insurance personnel
- Manages Macess workflow queues according to Claims department policies, guidelines, 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, 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, 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, PFS Billing system

BASIC QUALIFICATIONS:

- Bachelor's degree or the equivalent relevant years of 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, and negotiating skills
- Knowledge of Medicare and other insurance products
- Demonstrated writing and reporting skills

PREFERRED QUALIFICATIONS:

- 1 year in a customer service environment
- Experience working with cross-functional teams