Manager, Benefits Coordination and Claims

Principal Accountabilities

• Oversee end-to-end COB operations, including identification and validation of Other Health Insurance (OHI), Medicare Secondary Payer (MSP) processing, and commercial coordination rules.
• Ensure accurate application of Medicare, Medicaid, Essential Plan, Exchange, and Commercial Group Health Plan COB rules.
• Ensure full compliance with Centers for Medicare & Medicaid Services (CMS) regulations, including Medicare Secondary Payer (MSP) requirements, and Section 111 quarterly filings.
• Maintain adherence to federal and state COB regulations across all product lines, including Medicaid and Exchange plans.
• Investigate and resolve complex COB claim denials, payment disputes, and escalated provider or member inquiries.
• Identify root cause of issues and work with internal teams to improve processes and close process gaps.
• Collaborate and work cross-functionally with other operational areas (Claims, Provider Network Management, Contract Configuration, Provider File Operations, Payment Integrity, etc.) to ensure root causes are remediated for both overpayment and underpayments.
• Lead internal and external compliance audits and regulatory obligations.
• Implement corrective action plans in response to audit findings, regulatory updates, or compliance reviews.
• Support internal and external audits by maintaining accurate documentation, policies, and standard operating procedures.
• Partner with Claims, Enrollment, Finance, Compliance, and IT to ensure data integrity, accurate eligibility verification, and system optimization.
• Responsible for vendor relationships and recovery audit processes, as applicable.

Qualifications

• 5 – 8+ years’ relevant work experience in claims operations within a health insurance carrier environment required
• Bachelor’s degree required; additional experience/specialized training may be considered in lieu of degree
• Demonstrated expertise in Medicare, Medicaid, Essential Plan, Exchange, and Commercial Group Health Plan Coordination of Benefits rules required
• 5+ years’ experience managing staff / processes required
• In-depth knowledge of HIPAA regulations and CMS guidelines, including Medicare Secondary Payer requirements required
• Strong understanding of COB investigative processes, overpayment recovery methodologies, and denial management required
• Proficiency with claims processing platforms such as Facets and related eligibility and enrollment systems required
• Advanced analytical skills with the ability to interpret claims data, identify trends, and implement corrective strategies required
• Excellent communication and leadership skills with the ability to drive accountability and cross-functional collaboration required
• Strong organizational and auditing skills and attention to detail with a focus on operational efficiency and compliance integrity required
• Ability to effectively organize, prioritize, and manage multiple tasks/projects with simultaneous conflicting deadlines required
• Strong analytic, decision‐making, and problem‐solving abilities required
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
• Demonstrated leadership skills in a matrix environment required
• Ability to discern and identify patterns/trends of issues and provide recommendations for resolution required