Conduct in-depth COB investigations to establish primary and secondary coverage
Analyze comprehensive data sources such as COB Smart, HEW, claims, and membership data
Navigate and adapt to multiple internal and external client systems
Initiate and manage sensitive communications with stakeholders
Ensure accuracy in membership data updates
Apply client-specific COB methodologies for appropriate claims adjudication
Identify and rectify incorrectly paid claims
Maintain compliance with vendor SLAs, state and federal guidelines, and employer group contracts
Perform additional duties as necessary to support vendor operations and client services

Requires a H.S. diploma or equivalent
Minimum of 2 years of claims processing and/or customer service experience
At least 2 years of experience in claims processing and customer service highly desired
2 years of COB investigation experience is desired
Strong understanding and application of Medicare Secondary Payer (MSP), NAIC guidelines, ERISA, and other relevant regulations
AA/AS or higher level degree in healthcare administration or insurance is preferred
Proficiency in Microsoft Office Suite, specifically Excel, Word, Outlook, and Teams
Experience with claims processing software and SQL/data analysis tools is preferred
Expertise in Advanced Negotiation & Dispute Resolution, particularly in handling COB appeals and coverage disputes
Self-motivated with ability to prioritize and manage high-volume caseloads, adhering to strict SLAs
Strong team collaboration skills
Exceptional attention to detail

Investigator II, Coordination of Benefits

Key skills