Job Details

GENERAL SUMMARY:
The COB Recovery Specialist plays a pivotal role in advancing Coordination of Benefits (COB) and Medicare Secondary Payer (MSP) recovery efforts by independently resolving complex coverage issues and workflow initiatives. The COB Recovery Specialist will be a self-starter with strong decision-making capabilities and a deep understanding of COB processes in a health plan environment. The COB Recovery Specialist ensures compliance with State law, Medicare Secondary Payer (MSP) rules, National Association of Insurance Commissioners (NAIC) guidelines, and internal policies and procedures.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Apply specialized knowledge to independently resolve escalated or high-complexity COB cases, including disputes involving dual/multiple coverage determinations.
• Exercise discretion in interpreting CMS guidance and internal policy to make determinations on MSP recoverability, premium adjustments, and claim reimbursement strategies.
• Support and contribute to the Medicare Secondary Payer (MSP) demand and claims recovery process, ensuring appropriate coordination with providers, CMS, and internal finance or compliance teams.
• Monitor daily COB operations to ensure timeliness, accuracy, and adherence to standards; evaluate workflow bottlenecks and reassign work based on critical need.
• Provide direct training, mentoring, and guidance to junior staff, including developing and implementing procedural documentation.
• Coordinate and lead small to mid-scale projects focused on operational improvements, system enhancements, or regulatory compliance initiatives.
• Represent the department in cross-functional workgroups.

• Associate's degree (or equivalent combination of education and relevant experience). Bachelor's degree in health administration, business, or related field preferred.
• At least four (4) years of experience in COB operations and investigations including researching and resolving Workers' Comp, auto injuries, minor dependent overlap, and Medicare eligibility conflicts.
• Three (3) years of COB recordkeeping and documentation experience.
• One (1) year of experience in data analysis or report preparation.
• Minimum of four (4) years of experience in healthcare, medical billing, or insurance claims coordination preferred
• Minimum of four (4) years of experience making COB determinations with working knowledge of MSP, NAIC guidelines, and COB regulatory frameworkspreferred.
• Proficiency in Microsoft Office Suite (Word, Excel, Outlook), Power BI, and EDW preferred.

• Self-starter with strong decision-making capabilities and a deep understanding of COB processes in a health plan environment.
• Ability to independently resolve complex coverage issues.
• Strong verbal and written communication skills.
• Proven ability to manage multiple tasks and deadlines effectively in a fast-paced environment.
• Strong analytical, critical thinking, and problem-solving abilities.
• Detail-oriented with the ability to interpret eligibility and claims data accurately.
• Familiarity with basic medical terminology and healthcare coding a plus.