Coordination of Benefits Representative

This position is responsible for the overall Coordination of Benefits (COB) process within the Payment Integrity department. This includes ensuring that the member's enrollment records accurately reflect their primary/secondary coverage, leading to correct claims payment. This position investigates and resolves via outbound calls to other insurers, and CMS, as well as vendor partners and providers about COB leads generated from internal and external sources while meeting or exceeding designated quality standards. Identifies areas of improvement and works closely with interdepartmental teams around system enhancements. Reports upon COB metrics, as assigned. The COB Representative must have a comprehensive understanding of various regulations as related to COB and must complete all duties with strict regard to policies and procedures.

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:

• Act as COB Operations Subject Matter Expert (SME) in the documentation and communication of department policies and procedures
• Continuously monitor and update all COB-related operations documentation
• Works closely with other carriers, including Commercial payers, and CMS, as well as interdepartmental staff in Claims and Member Services to ensure the accuracy of COB coverage

• Works directly with the department's management team and staff to ensure all documentation is accurate and easy to understand
• Work with line-level staff specialists and analysts to help streamline procedures and guidelines to improve operational efficiency
• Provides timely feedback to leadership regarding claims documentation opportunities for improvement and successes

• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications

Required:

• Bachelor's degree in business, education, health care related field or equivalent work experience

• Four (4) years' experience in a health care claims or Member Services/Enrollment setting
• Two (2) years' coordination of benefits experience, possessing deep knowledge of Commercial, Government Programs (Medicare and Medicaid) COB processes

• Proven ability to effectively document procedures and guidelines in a consumable format for end-users to understand in order for staff to adequately perform their jobs
• Actively communicates with team members at all levels, to clarify information and to communicate claims COB requirements accurately
• Demonstrated decision-making skills
• Strong, clear communication skills (written/verbal)
• Excellent attention to organization and detail
• Ability to quickly learn the functions of the department and related departments, as well as documented processes and functionality
• Proficient working knowledge of Microsoft Office (Word, Excel, PowerPoint, Visio) that will be used to develop and present material

• Requires the ability to assess all work and prioritize as necessary - must be highly organized and be able to juggle multiple priorities effectively
• Must be able to work independently, and as part of a team, with minimum amount of direction
• Must be confident in ability to decisively act upon issues

• An understanding of Third Party Liability (TPL), Motor Vehicle Accident (MVA), and Subrogation carrier benefits coordination

• Working knowledge of health care payer functions
• Project management experience
• General knowledge of CPT-4, ICD-9-CM and ICD-10 coding principles and guidelines

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.