Benefits Administration - CW Claims Specialist II

Job Profile

Summary:

CW Claims Specialist II

Preferred candidates must have COB experience: COB experience refers to hands‑on work determining which insurance plan pays first when a member has multiple sources of coverage, and ensuring claims are processed correctly based on that order.

• Identifying primary vs. secondary coverage when a member has more than one health plan
• Reviewing and updating claims to reflect correct COB rules
• Applying COB primacy rules (subscriber status, effective dates, plan type, Medicare coordination, etc.)
• Communicating with members, providers, and other insurers to verify coverage details
• Correcting over payments, initiating refunds or reprocessing, and maintaining accurate claim records
• Working within claims systems and following regulatory and compliance requirements (e.g., HIPAA)

Duties may include the following responsibilities or functions required to support the claims unit. Accurate processing of claims edits, determining primacy for the Coordination of Benefits (COB), adjusting previously paid claims and initiating procedures to recover funds on overpaid claims. Analyzing, investigating, and resolving problem cases; executing recovery processes; and completing special projects. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.

• This role does not manage people
• This role reports to this job: SUPERVISOR, CLAIMS OPERATIONS

Necessary Contacts:
To effectively fulfill this position, Claims Specialist II must be in contact with personnel in other Units:
Various internal departments and staff including, but not limited to, Provider Services, Legal, Internal Audit, IT, other Benefits Operations Management and staff, Enrollment and Billing, Administrative Services, and District Offices.

Various external entities including, but not limited to, Providers, Members, Lawyers, Groups, Commissioner of Insurance, other insurance companies, and other Plans.

Education

• High School Diploma or equivalent required

Work Experience

• 2 years in medical claims processing required
• Coordination of Benefits (COB) processing experience preferred

Skills and Abilities

• Strong analytical ability, that includes strong logical, systemic, and investigating thinking.
• Strong oral and written communication skills and human relations skills are necessary.
• Working knowledge of relevant PC software.
• Ability to prioritize multiple streams of work effectively.

Licenses and Certifications

• None Required

Reviews, research, and make necessary updates to claims that may include the following: recalculation of benefits to previously processed claims, the processing of claims edits, or initiation of refund requests, according to contractual benefits or provider reimbursement rules, ultimately providing a high degree of customer satisfaction.

• Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify denial codes, edits, and processing codes pertaining to all claims (including our coordination with additional coverage plans) to process both coordinated and non‑coordinated claims correctly. Requesting medical records may be required.
• Communicates, both orally and in writing, with internal and external contacts to provide necessary and accurate information for the establishment of sound claims records. This may include, but is not limited to, the coordination of benefits (COB), medical record requests, etc.
• Review quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.
• Research, investigates, and determines the correct order of benefits for payment to be made by the applicable plans and makes necessary corrections to COB records. Communicates to appropriate department(s) when Medicare has determined primacy incorrectly and ensures a letter is generated to notify Medicare. Failure to report discrepancy could result in a daily fine up to $1,000.00.
• Analyzes, investigates, resolves problem cases (to include COB records,…