Coordination of Benefits Specialist

1 month ago

Northridge, United States REGAL MEDICAL GROUP, INC Full time

**Position Summary**:
This position is directly responsible for researching and maintaining coordination of benefits of all contracted and non contracted health plan entities as reported by any health plan, provider, Medicare, TPL, Workers Comp or internal departments. They are to ensure that all EZ-Cap system eligibility data is current and accurate. Researches and maintains systems and changes to existing eligibility in a timely manner.

**Essential Duties and Responsibilities**:

- When a COB requests are received from internal departments and corporate employee will determine if the health plan and CMS reflect correct COB information.
- Staff will contact the health plan and verify if the policy is an active employer group policy (large or small) or a retiree policy and obtain a retiree date.
- Staff will contact the member to confirm their employer group status, active or retired. (Only when the health plan cannot confirm a retiree date, number of employees or any other pertinent information necessary to establish COB according to Medicare guidelines).
- Staff will notify the employer group to advise them the health plan shows member actively employed, when per the member, they are retired.
- Review Medicare guidelines to determine if they have obtained all the necessary information from the health plan, employer group, or member to establish correct COB.
- Contact the CMS COB unit to report that there is or there is no COB if CMS shows Medicare Secondary Payer information.
- Document in EZ-Cap in the notes field of all activity, calls, CMS MSP status, etc. and respond to appropriate departments of any changes in coordination of benefits.
- Update COB field in EZ-Cap to reflect correct MSP status according to Medicare guidelines even when CMS & health plan do not yet reflect correct MSP.
- Follow up with CMS and the health plan in 5 to 10 business days to verify information has been update by both CMS and the health plan. (Continue to follow up with CMS, health plan and member if necessary).
- Communicates verbally and supplies a summary of COB status at weekly Membership meetings. Is responsible of educating staff and keeping up with changes in Medicare Guidelines.
- Maintains End Stage Renal Disease Database. Communicates ESRD updates to all appropriate departments.
- Performs research and analysis of membership
- Enters new member eligibility records into EZ Cap in accordance with established guidelines.
- Uses activity analysis reports from the health plans to make changes to existing enrollees; i.e. benefit option changes, terminations, and address changes.
- Manually audits existing eligibility in EZ Cap against current eligibility.
- Investigates retroactive cancellations for services rendered by the member after the policy termination date for eligibility guarantee.
- Researches problem eligibility on authorizations and/or claims forms by calling the health plans or utilizing any other source to resolve the problem.
- Assists personnel from other departments with eligibility issues.
- All other duties as directed by management.

**Education and/or Experience**:

- Three years office experience in Managed Health Care
- Must have knowledge of HMO, PPO, EPO, POS, Government Funded, Medicare and Medicaid plans
- Must have knowledge of the Department of Managed Healthcare COB guidelines
- Experience with Windows, Microsoft Office programs, and Outlook
- Experience in Customer Service

The pay range for this position at commencement of employment is expected to be between ; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

Full Application:
Pay: $20.00 - $22.00 per hour

**Benefits**:

- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance

Schedule:

- 8 hour shift
- Day shift
- Monday to Friday

People with a criminal record are encouraged to apply

Ability to Relocate:

- Northridge, CA 91325: Relocate before starting work (required)

Work Location: In person

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