Benefits Coordination and Recovery Specialist

About the role

Responsible for investigating common and complex coordination of benefits (COB) and other party liability issues, determining and updating member liability insurance information to ensure accurate claims adjudication. Identify primary vs. secondary payer order for Commercial, Medicare, and Medicaid lines of business. Update the claims system with correct COB flags and recover overpayments related to COB inaccuracies. Communicate with members, insurance carriers, employer groups, and CMS for clarification and resolution.

Responsibilities

• Research and analyze member eligibility data from multiple sources including internal systems, phone calls to members/providers, CMS, and other carriers to determine correct payer order (primary, secondary, or tertiary).
• Accurately update the claims system (e.g., Facets, QNXT) with COB flags, coverage details, and policy terms to ensure compliant and accurate future claims processing.
• Conduct mandatory investigations to identify "Working Aged," "Disability," and "End-Stage Renal Disease (ESRD)" status.
• Identify, calculate, and initiate recovery of COB-related overpayments.
• Interface with the Benefits Coordination & Recovery Center (BCRC) and update the Common Working File (CWF) to ensure the global Medicare record accurately reflects other health insurance (OHI).
• Identify and resolve "conditional payments" that were not paid correctly.
• Maintain a deep understanding of, and strictly adhere to, regulatory compliance standards including COB rules, state/federal regulations, and guidelines for Medicare, Medicaid, and Commercial insurance.
• Research and correct CMS submission errors and fallout to ensure primacy is set correctly and coverage changes are submitted to CMS on a timely basis in accordance with quality and compliance standards.
• Troubleshoot and identify system issues; highlight potential solutions to leadership and document findings.
• Identify, fix, and eliminate any "coordination of benefits" issues that are inaccurate or incomplete.
• Initiate professional communication with providers, insurance carriers, and members to verify coverage information and resolve coordination inquiries.
• Maintain detailed, accurate, and timely documentation of investigation results and recovery activities in company databases.
• Assist in the collection and validation of data required for Section 111 of the MMSEA, ensuring accurate member records are transmitted to CMS to avoid civil monetary penalties.
• Maintain detailed documentation of COB investigations to satisfy CMS "Pay and Chase" audits and Medicaid Third Party Liability (TPL) requirements.
• Oversee "crossover" claim processes in accordance with COBA standards, ensuring supplemental and secondary claims are transmitted to the correct payers without duplication.
• Perform other duties as assigned or required.

Requirements

• 3–5+ years of experience in health insurance claims, COB investigation, claims recovery, or payment integrity.
• Solid understanding of COB investigative methodologies, overpayment recovery processes, and denial resolution.
• Proficiency with claims processing systems such as Facets and related eligibility and enrollment platforms.
• Strong written and verbal communication skills with the ability to effectively partner with regulatory agencies and external insurers.
• Detail-oriented with a focus on operational accuracy, compliance integrity, and overpayment prevention.
• Ability to manage multiple complex cases simultaneously in a fast-paced environment.
• Strong analytic, decision-making, and problem-solving abilities.
• Strong investigative skills, with proven ability to gather and interpret Explanation of Benefits (EOB), including use of online payer portals, answer questions, and resolve standard as well as complex issues with payments.
• Ability to follow policy, procedures, and regulations in the workplace, and demonstrates ability to lead by example and support development of junior team members.
• Ability to effectively perform work independently and work cooperatively with others to promote a positive team environment.
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.).

Qualifications

• Bachelor’s degree in healthcare administration or related field required; additional experience/specialized training may be considered in lieu of degree.

Pay

Hiring range: $56,160–$99,360