Remote eCOB Specialist II: Claims & Coverage Expert

Responsibilities

• This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy.
• Responsible for researching and investigating other coverage for all of the company's groups and members on multiple platforms.
• Fully proficient in all key areas; performs multi complex functions and interprets complex rules, laws and contracts.
• Accountable for end-to-end functionality on every Coordination of Benefits (COB) function including reconciliation of claim, membership and accounting.
• Utilizes internal queries, internal resource tools, must initiate delicate-in-nature phone calls to other carriers, members, groups, providers, attorneys, CMS and Medicaid and report to identify members who are or should be enrolled in other coverage.
• Aides members in enrolling in Medicare when they are entitled.
• Determines primacy on each case using a complex set of Primacy Rules as mandated by State and Federal Laws, such as CMS Primacy and NAIC rules and comparing them against the member/groups benefits.
• Updates all of the company's membership system components with investigation results for claim coordination.
• Ensures correct forms are provided to assist members enrolling in Medicare.
• Reviews claim history to identify claims requiring reconciliation, whether processed or pended, as well as recovered in error.
• Associate must identify the correct formulas in order to adjudicates impacted claims, using multiple COB Formulas for the various product types, pursuant to State and Federal Guidelines.
• Expected to have the ability to multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.

• eCOB Specialist II:
  Requires a HS diploma or equivalent and a minimum of 2 years of claims processing and customer service and 2 years COB experience that required using NAIC & CMS COB guidelines; or any combination of education and experience which would provide an equivalent experience.
• eCOB Specialist III:
  Requires a HS diploma or equivalent and a minimum of 3 years of claims processing and customer service and 3 years COB experience that required using NAIC & CMS COB guidelines; or any combination of education and experience which would provide an equivalent background.
• Newborn benefits experience strongly preferred.
• WGS experience strongly preferred.
• Strong organizational and time management skills preferred.

Proficient in Coordination of Benefits (COB) processes, including claims processing, membership updates, and adherence to NAIC and CMS guidelines. Strong ability to manage multiple tasks and communicate effectively with members and other stakeholders.