Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Coordination of Benefits and Recovery Specialist
REMOTE
Summary of Position
- Responsible for investigating common and complex coordination of benefits 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 recovering overpayments related to COB inaccuracies.
- Communicate with members, insurance carriers, employer groups, and CMS for clarification and resolution.
Principal Accountabilities
- 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.
- Trouble-shoot and identify system issues; highlight potential solutions to leadership and document findings.
- Identifies, fixes and eliminates 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.
- 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).
- 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.
Qualifications
Education, Training, Licenses, Certifications
- Bachelor’s degree in healthcare administration or related field required; additional experience/specialized training may be considered in lieu of degree
Relevant Work Experience, Knowledge, Skills, and Abilities
- 3 – 5+ year of experience in health insurance claims, COB investigation, claims recovery, or payment integrity required
- Solid understanding of COB investigative methodologies, overpayment recovery processes, and denial resolution required
- Proficiency with claims processing systems such as Facets and related eligibility and enrollment platforms required
- Strong written and verbal communication skills with the ability to effectively partner with regulatory agencies and external insurers required
- Detail-oriented with a focus on operational accuracy, compliance integrity, and overpayment prevention required
- Ability to manage multiple complex cases simultaneously in a fast-paced environment required
- Strong analytic, decision‐making, and problem‐solving abilities required
- 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 required
- Ability to follow policy, procedures, and regulations in the workplace, and demonstrates ability to lead by example and support development of junior team members required
- Ability to effectively perform work independently and work cooperatively with others to promote a positive team environment required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.