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POSITION SUMMARY

The Coordination of Benefits Specialist I is responsible for researching, investigating, and maintaining accurate Other Health Insurance (OHI) and Coordination of Benefits (COB) information for members. This role ensures accurate identification of primary, secondary, and tertiary coverage by leveraging data from the Centers for Medicare & Medicaid Services (CMS) eligibility files, internal systems, and external carrier sources. The eCOB Specialist I ensures accurate COB data integrity at the time of claims processing and is responsible for updating membership records to support correct claims adjudication, financial accuracy, and compliance with CMS requirements and Medicare Secondary Payer (MSP) rules.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:

Key Responsibilities

• Research and investigate potential other insurance coverage for all members and employer groups using CMS eligibility files, internal systems, and external data sources.
• Maintain accurate Coordination of Benefits (COB) records to ensure correct payer sequencing during claims processing.
• Identify, validate, and update Medicare and other insurance coverage indicators in membership systems, including CMS-derived enrollment data.
• Review CMS file discrepancies and ensure accurate reflection of primary and secondary coverage in health plan systems.

COB & Eligibility Management

• Perform end-to-end Coordination of Benefits (COB) activities, including identification, verification, and maintenance of other insurance coverage.
• Reconcile membership, claims, and eligibility data to ensure consistency across systems.
• Analyze claim history to identify coordination issues, overpayments, or incorrect primary payer assignments.
• Apply Medicare Secondary Payer (MSP) rules and other applicable coordination guidelines to determine correct liability.

Investigation & Outreach

• Utilize internal and external resources to identify other coverage, including proprietary tools, CMS files, and payer databases.
• Conduct outbound research activities, including phone calls and written correspondence to:
  • Other insurance carriers
  • Members and dependents
  • Employers and groups
  • Providers
  • Attorneys or third-party representatives
  • CMS and Medicaid agencies
• Assist members with understanding Medicare eligibility and enrollment requirements when applicable.
• Provide guidance and appropriate documentation to support member enrollment in Medicare or other coverage when entitlement is identified.

System Updates & Data Integrity

• Update membership and eligibility systems with verified COB findings.
• Ensure accurate coding and configuration of primary and secondary coverage indicators in CMS-aligned records.
• Maintain data integrity across all system platforms to support claims adjudication accuracy.
• Identify and correct system discrepancies related to COB, eligibility, and CMS enrollment data.

Claims Coordination Support

• Review impacted claims to ensure proper coordination based on verified COB information.
• Identify claims that require reprocessing, adjustment, or recovery due to incorrect primary payer assignment.
• Support claims operations by providing accurate COB data to ensure proper adjudication outcomes.
• Collaborate with claims and recovery teams on coordination-related adjustments and resolutions.

Compliance & Regulatory Requirements

• Ensure all COB and eligibility activities comply with CMS Medicare regulations and Medicare Secondary Payer (MSP) requirements.
• Maintain confidentiality and security of protected health information (PHI) in accordance with HIPAA and organizational policies.
• Document all investigation activities, findings, and system updates in accordance with audit and compliance standards.

Documentation & Reporting

• Maintain detailed documentation of COB investigations, including sources reviewed, outreach performed, and final determinations.
• Track and report trends related to COB discrepancies, CMS file inconsistencies, and eligibility errors.
• Support audit requests and regulatory reviews by providing clear and accurate records of COB activity.

QUALIFICATIONS AND EDUCATION

Minimum Qualifications

• High School Diploma or GED required.
• Minimum of 3–5 years of experience in healthcare claims, eligibility, COB, or Medicare coordination functions.
• Experience working with CMS eligibility files, Medicare Advantage, or Medicare Secondary Payer (MSP) rules preferred.
• Strong understanding of insurance coordination principles and healthcare claims processing.
• Equivalent combination of education and experience may be considered.

Preferred Qualifications

• Experience with CMS enrollment data and Medicare eligibility processes.
• Familiarity with COB recovery processes and claims adjustment workflows.
• Knowledge of managed care operations and multi-payer coordination.
• Experience using claims or membership systems in a health plan environment.

Skills & Competencies

• Strong investigative and analytical skills
• High attention to detail and data accuracy
• Ability to interpret complex coordination rules and regulatory guidance
• Strong communication skills for members and carrier outreach
• Ability to manage multiple research cases independently
• Proficiency in documentation and system data entry

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Employee Acknowledgement:

I have read this job description and understand what is expected of me while I occupy this role.