Carelon Coordination of Benefits (COB) - Investigator II

Carelon Coordination Of Benefits (COB) - Investigator II Internal Job Title: Financial Operations Recovery Specialist II Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance will not be considered unless an accommodation is granted as required by law. Carelon , a proud member of the Elevance Health family of companies, provides healthcare services that focus on making care integrated, personalized, and affordable. Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate, and prevent unnecessary medical‑expense spending. The role is tasked with conducting thorough investigations into potential other coverages, accurately determining primacy, and ensuring seamless coordination of benefits across multiple vendor clients, employer groups, and government and specialty lines. The position demands proficiency in multi‑system data analysis, claims adjudication, regulatory compliance, and handling complex cases beyond automated systems. How You Will Make An Impact Conduct in‑depth COB investigations to establish primary and secondary coverage, utilizing NAIC, CMS, MSP, ERISA, and other federal and state regulations. Analyze comprehensive data sources such as COB Smart, HEW, claims, and membership data to verify coverage and resolve discrepancies. Navigate and adapt to multiple internal and external client systems with varying claims processing methodologies and requirements. Initiate and manage sensitive communications with stakeholders including insurance carriers, members, providers, attorneys, CMS, and Medicaid. Ensure accuracy in membership data updates, enabling correct future claims processing. Apply client‑specific COB methodologies for appropriate claims adjudication and payment reconciliation. Identify and rectify incorrectly paid claims, ensuring precise adjustments, reprocessing, and refund recovery. Maintain compliance with vendor SLAs, state and federal guidelines, and employer group contracts. Perform additional duties as necessary to support vendor operations and client services. Minimum Qualifications Requires a high school diploma or equivalent and a minimum of 2 years of claims processing and/or customer service experience; or any combination of education and experience that provides an equivalent background. Preferred Skills, Capabilities, And Experiences At least 2 years of experience in claims processing and customer service highly desired. 2 years of COB investigation experience, with strong understanding and application of Medicare Secondary Payer (MSP), NAIC guidelines, ERISA, and other relevant regulations. AA/AS or higher level degree in healthcare administration or insurance preferred. Proficiency in Microsoft Office Suite, especially Excel, Word, Outlook, and Teams; experience with claims processing software and SQL/data analysis tools preferred. Expertise in Advanced Negotiation & Dispute Resolution, particularly in handling COB appeals and coverage disputes. Self‑motivated with the ability to prioritize and manage high‑volume caseloads, adhering to strict SLAs. Strong team collaboration skills, capable of working effectively within a cross‑functional team while also independently managing investigations. Exceptional attention to detail to ensure claim adjudication accuracy, membership updates, and compliance with documentation standards. Equal Employment Opportunity Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact View email address on click.appcast.io for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including but not limited to the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration. #J-18808-Ljbffr Elevance Health