Payment Accuracy Specialist 1 (Coordination of Benefits

Overview

A Payment Accuracy, Coordination of Benefits (COB) Specialist 1 is a member of the greater Coordination of Benefits Business Unit (BU). Coordination of Benefits involves situations in which an individual is covered by two or more health plans.

This role is responsible for reviewing and analyzing the multi-client impact, complex member selection, and query or filter construction of data to identify instances of recoverable Coordination of Benefit claims for the benefit of Cotiviti and our clients. This individual works under limited supervision and is responsible for establishing the correct order of liability for our client’s members. Additionally, they input accurate claim recovery information in the proprietary Cotiviti software tools and assist with related inquiries throughout the claim recovery process.

The position involves responsibility for moderate to more complex audit projects, ranging from low to midrange in scope.

• This individual will work under limited supervision and will be monitored for efficiency in production and quality review of assigned work.
• Demonstrates the ability to excel both independently and as a collaborative team player.
• The scope of work involves complex member selections and multi-client impacts.
• Capability and comfort in running and establishing queries and filters for construction and data reports.
• Demonstrates proactive problem-solving skills and a keen ability to resolve data-related challenges efficiently, contributing to a solution-driven environment.
• Possesses an in-depth knowledge of Centers for Medicare and Medicaid Services (CMS) and National Association of Insurance Commissioners (NAIC) guidelines, crucial for determining liability accurately.
• Utilizes Cotiviti audit tools (Recovery Management System (RMS), COB Tracker, specific client systems) to complete member investigations.
• Creates detail-oriented, accurate notes in Cotiviti audit tools and/or client tools throughout the member investigation.
• Meets or exceeds standards of production and quality as identified by compliance and regulatory guidelines and set forth by the Team Lead and/or Manager when reviewing concept and claim identifications for the client.
• Prepares and evaluates responses to client disputes both internally and externally within the Business Unit as needed.
• Identifies opportunities for continuous improvement for efficiencies within reporting and streamlining research processes.
• Demonstrates understanding of Cotiviti policies & procedures, and external regulatory requirements and performs duties in accordance with such regulatory requirements.
• Demonstrates a deep understanding of the healthcare industry and a track record of delivering exceptional results.
• Assures confidentiality and security of all data, adhering to all HIPAA (Health Insurance Portability and Accountability) laws and requirements. Demonstrates the skills, knowledge, and ability to ensure that our environment is a safe one, complying with industry standards.
• Has ability to take responsibility for outcome, whether positive or negative and apply learning as applicable.
• Integrates information from various sources and considers broader context.
• Creates innovation to enhance the standard operating rhythm finding new pathways to complete work expectations.
• Actively seeks information to understand rationale and provide exceptional results beyond basic standards.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change.

• High School Diploma - Required.
• Bachelor’s degree (Preferred) and/or a minimum of at least two (2) years related experience in healthcare.
• At least 1-2 years of Cotiviti experience is recommended for individuals seeking their next opportunity internally (e.g., employees in current COB Specialist or Payment Accuracy Specialist roles).
• Healthcare industry experience, including knowledge of Coordination of…