Sr. Coordination of Benefits and Recovery Specialist

COB Specialist

REMOTE

Summary of Position

Responsible for leading complex COB investigations across all lines of business, including governmental and commercial products, educating and resolving the discrepancies with insurance carriers, employers and providers. Ensure accurate determination of payer responsibility, protect organizational revenue, and maintain compliance with federal and state regulations. Serve as a subject matter expert, providing guidance, training, and quality oversight to COB Specialists while supporting operational excellence, overpayment prevention, and continuous improvement initiatives.

Principal Accountabilities

• Lead and conduct complex COB investigations for Medicare, Medicaid, Essential Plan, Exchange, and Commercial Group Health Plan claims.
• Research and resolve escalated claim denials, payment discrepancies, overpayments, and recovery cases.
• Analyze policy documents, Evidence of Benefits (EOBs), eligibility records, and contractual language to accurately determine primary and secondary payer responsibility.
• Identify and validate Other Health Insurance (OHI) coverage and ensure correct application of Coordination of Benefits rules.
• Serve as a subject matter expert (SME) for governmental and commercial COB regulations, providing guidance and case consultation to COB analysts.
• Deliver training and mentorship to team members to enhance technical expertise, regulatory knowledge, and investigative effectiveness.
• Partner with external entities including CMS, Treasury Dept, Medicare Commercial Repayment Center, commercial insurers, and third-party administrators to validate coverage and resolve complex payer disputes.
• Manage CRC portal and Open Debt reports. Review internal investigation and vendor reports to ensure timeliness and accuracy.
• Monitor trends in COB errors, denials, and recoveries; recommend corrective actions and process improvements to strengthen operational efficiency.
• Support cross-functional collaboration with Claims, Enrollment, Compliance, Finance, and IT to ensure data accuracy and proper claims adjudication.
• Ensure adherence to CMS guidelines, including Medicare Secondary Payer (MSP) requirements and reporting obligations.
• Maintain compliance with federal and state Medicaid COB regulations and commercial coordination standards.
• Support internal audits, regulatory reviews, and external examinations by maintaining accurate case documentation and investigative records.
• Contribute to corrective action plans and continuous quality improvement initiatives in response to audit findings or regulatory changes.
• Participate in system testing, policy updates, and workflow enhancements related to COB processes.
• Perform other duties as assigned or required.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's degree required; additional experience/specialized training may be considered in lieu of degree

Relevant Work Experience, Knowledge, Skills, and Abilities

• 4 – 6+ years of relevant work experience in a healthcare environment required
• Comprehensive knowledge of HIPAA regulations & CMS guidelines, including Medicare Secondary Payer (MSP) provisions required
• Strong analytical skills with the ability to interpret policy documents, EOBs, eligibility files, and regulatory requirements required
• Expertise in 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; ability to effectively liaise with regulatory agencies and external insurers required
• Detail-oriented with a focus on operational accuracy, compliance integrity, and revenue protection 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; effectively serve as subject matter expert, lead by example, and to contribute to team results and progress required
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required