Payment Integrity Lead - Coordination of Benefits (COB)

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
• Annual incentive bonus plan based on company achievement of goals
• Time away from work including paid holidays, paid time off and volunteer time off
• Professional development courses, mentorship opportunities, and tuition reimbursement program
• Paid parental leave and adoption leave with adoption financial assistance
• Employee discount program

Payer Priority Determination and Complex Claims Resolution:

• Identifies areas of improvement and implements proactive solution recommendations partnering with internal and external stakeholders at all levels of the organization. Analyzing current COB workflows to identify inefficiencies, develop and implement improvements to streamline claim adjudication and reduce errors.
• Utilizes Medicare expertise in conjunction with strong analytical and collaboration skills to partner with matrix partners and vendors ensuring accurate and timely benefit primacy determination in complex scenarios
• Investigating and resolving complex COB issues such as coordinating with multiple insurance companies including federal and state programs, to resolve discrepancies.
• Accountable for the annual review of policies and procedures to ensure compliance with current regulatory and industry standards.
• Strong partnerships with claims processing teams, provider relations, IT, and compliance departments to ensure smooth COB integration and adherence to regulations.
• Builds collaborative relationships across people and teams, including all levels in the organization. Acts as role model

Staff Training and Development:

• Coaching and mentoring team members and peers ensuring accurate claims adjudication and staying updated on changing industry regulations. Training responsibilities include not only the loading on COB information into adjudication systems, but also vendor support programs that support internal investigations of primacy determinations through state and federal databases or vendor supplied, such as CAQH.

Minimum Qualifications

• Bachelor's degree in Business Administration, Computer Science or related field; or an equivalent combination of education and experience
• 5 years of experience with the full life cycle of Coordination of Benefits (COB), Membership or Claims Records, including the oversight of vendor contracts and systems to support COB determinations and Compliance management with state and federal COB regulations.
• Experience with health plan operations including claims payment including review and analysis, payer priority determination, and experience working with provider offices, other payers and vendor partners.
• Experience with document management software platforms such as Perceptive, to for inventory management and work assignment.
• Experience with payor claims adjudication systems, including Member and Provider Inquiries.
• Experience handling complex Coordination of Benefits payer priority determinations using external vendor systems including CAQH and Medicare as well as internal resources and member interviews.
• Strong Analysis skills to support inventory management, validation of current processes, development of reporting to support COB program savings
• Vendor liaison for COB vendors to include reviewing reporting, handling invoicing, touch base meetings.
• Intermediate level knowledge of Microsoft Office.
• Proven ability to manage inventory and resource assignments to meet SLA and turn around times.
• Proven ability to create and train other team members on current SOP and best practices.

Preferred Qualifications

• Advanced knowledge of Microsoft Office
• Advanced knowledge of Facets Claims processing systems or similar claims adjudication platforms
• Previous experience with Vendor Management and coordination for software support
• Proven ability to manage inventory and resource assignments to meet SLA and turn around times.

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.