Payment Accuracy Specialist 1 (Coordination of Benefits)

Role Description

A Payment Accuracy, Coordination of Benefits (COB) Specialist 1 is a member of the greater Coordination of Benefits Business Unit (BU). Coordination of Benefits involves situations in which an individual is covered by two or more health plans. This role is responsible for reviewing and analyzing the multi-client impact, complex member selection, and query or filter construction of data to identify instances of recoverable Coordination of Benefit claims for the benefit of Cotiviti and our clients. This individual works under limited supervision and is responsible for establishing the correct order of liability for our client’s members. Additionally, they input accurate claim recovery information in the proprietary Cotiviti software tools and assist with related inquiries throughout the claim recovery process. The position involves responsibility for moderate to more complex audit projects, ranging from low to midrange in scope.

• This individual will work under limited supervision and will be monitored for efficiency in production and quality review of assigned work.
• Demonstrates the ability to excel both independently and as a collaborative team player.
• The scope of work involves complex member selections and multi-client impacts.
• Capability and comfort in running and establishing queries and filters for construction and data reports.
• Demonstrates proactive problem-solving skills and a keen ability to resolve data-related challenges efficiently, contributing to a solution-driven environment.
• Possesses an in-depth knowledge of Centers for Medicare and Medicaid Services (CMS) and National Association of Insurance Commissioners (NAIC) guidelines, crucial for determining liability accurately.
• Utilizes Cotiviti audit tools (Recovery Management System (RMS), COB Tracker, specific client systems) to complete member investigations.
• Creates detail-oriented, accurate notes in Cotiviti audit tools and/or client tools throughout the member investigation.
• Meets or exceeds standards of production and quality as identified by compliance and regulatory guidelines and set forth by the Team Lead and/or Manager when reviewing concept and claim identifications for the client.
• Prepares and evaluates responses to client disputes both internally and externally within the Business Unit as needed.
• Identifies opportunities for continuous improvement for efficiencies within reporting and streamlining research processes.
• Demonstrates understanding of Cotiviti policies & procedures, and external regulatory requirements and performs duties in accordance with such regulatory requirements.
• Demonstrates a deep understanding of the healthcare industry and a track record of delivering exceptional results.
• Assures confidentiality and security of all data, adhering to all HIPAA (Health Insurance Portability and Accountability) laws and requirements.
• Has ability to take responsibility for outcome, whether positive or negative and apply learning as applicable.
• Integrates information from various sources and considers broader context.
• Creates innovation to enhance the standard operating rhythm finding new pathways to complete work expectations.
• Actively seeks information to understand rationale and provide exceptional results beyond basic standards.

Qualifications

• High School Diploma - Required.
• Bachelor’s degree (Preferred) and/or a minimum of at least two (2) years related experience in healthcare.
• At least 1-2 years of Cotiviti experience is recommended for individuals seeking their next opportunity internally (e.g., employees in current COB Specialist or Payment Accuracy Specialist roles).
• Healthcare industry experience, including knowledge of Coordination of Benefits (Required).
• Computer proficiency including Microsoft Office (Word, Excel, Outlook).
• Excellent verbal and written communication skills.
• Strong interest in working with large data sets and various databases.
• Ability to work well in an individual and team environment demonstrating self–motivation to deliver success.

Requirements

• Ability to analyze large volumes of data, identify trends, discrepancies, and anomalies.
• Exceptional attention to detail to ensure accuracy in financial records and audit findings.
• Strong critical thinking skills, with the ability to assess complex situations, identify key issues, and propose practical solutions.
• Able to approach challenges methodically and with a strategic mindset.
• Makes informed decisions based on available data, regulations, and auditing standards.
• Must be able to weigh options and make recommendations that align with both compliance requirements and organizational goals.
• Strong understanding of auditing standards, regulations, and industry best practices.
• Must be able to apply these standards consistently to ensure accurate and compliant audit processes.
• Ability to recognize when something is wrong or needs further investigation.
• Must have the initiative to probe deeper into financial records or processes to uncover issues, inconsistencies, or irregularities.
• Ability to work effectively as part of an audit team, sharing insights, collaborating on tasks, and contributing to a positive and productive team dynamic.

Physical Requirements and Working Conditions

• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• No adverse environmental conditions expected.
• Must be able to provide a dedicated, secure work area.
• Must be able to provide high-speed internet access / connectivity and office setup and maintenance.

Benefits

• Base compensation ranges from $22.60 to $26.00 per hour.
• Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs.
• This role is eligible for discretionary bonus consideration.
• Nonexempt employees are eligible to receive overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law.
• Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage.
• 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.