REMOTE Summary of Position
- Responsible for leading and optimizing the organization's secondary payer and revenue recovery processes across all lines of business, establishing performance metrics and accountability standards aligned with organizational goals.
- Lead, supervise, and develop a team of COB Specialists, establishing performance metrics and accountability standards aligned with organizational goals
- Ensure accurate identification and management of Other Health Insurance (OHI), compliance with CMS and regulatory requirements, and operational excellence within COB functions.
- Monitor and analyze COB metrics, denial trends, and recovery outcomes; implement process improvements to enhance operational effectiveness.
- Drive strategic initiatives to reduce claim overpayment, improve recovery outcomes, and strengthen financial performance while maintaining regulatory integrity.
Principal Accountabilities
- Oversee end-to-end COB operations, including identification and validation of Other Health Insurance (OHI), Medicare Secondary Payer (MSP) processing, and commercial coordination rules. Ensure accurate application of Medi Investigate and resolve complex COB claim denials, payment disputes, and escalated provider or member inquiries.
- Ensure accurate application of Medicare, Medicaid, Essential Plan, Exchange, and Commercial Group Health Plan COB rules.
- Ensure full compliance with Centers for Medicare & Medicaid Services (CMS) regulations, including Medicare Secondary Payer (MSP) requirements, and Section 111 quarterly filings.
- Maintain adherence to federal and state COB regulations across all product lines, including Medicaid and Exchange plans.
- Investigate and resolve complex COB claim denials, payment disputes, and escalated provider or member inquiries.
- Identify root cause of issues and work with internal teams to improve processes and close process gaps.
- Collaborate and work cross-functionally with other operational areas (Claims, Provider Network Management, Contract Configuration, Provider File Operations, Payment Integrity, etc.) to ensure root causes are remediated for both overpayment and underpayments.
- Lead internal and external compliance audits and regulatory obligations.
- Implement corrective action plans in response to audit findings, regulatory updates, or compliance reviews.
- Support internal and external audits by maintaining accurate documentation, policies, and standard operating procedures.
- Partner with Claims, Enrollment, Finance, Compliance, and IT to ensure data integrity, accurate eligibility verification, and system optimization.
- Responsible for vendor relationships and recovery audit processes, as applicable.
- Develop and deliver ongoing team training to ensure regulatory updates, policy changes, and system enhancements are effectively implemented.
- Perform other duties as assigned or required.
Qualifications
- 5 - 8+ years' relevant work experience in claims operations within a health insurance carrier environment required
- Bachelor's degree required; additional experience/specialized training may be considered in lieu of degree
- Demonstrated expertise in Medicare, Medicaid, Essential Plan, Exchange, and Commercial Group Health Plan Coordination of Benefits rules required
- 5+ years' experience managing staff / processes required
- In-depth knowledge of HIPAA regulations and CMS guidelines, including Medicare Secondary Payer requirements required
- Strong understanding of COB investigative processes, overpayment recovery methodologies, and denial management required
- Proficiency with claims processing platforms such as Facets and related eligibility and enrollment systems required
- Advanced analytical skills with the ability to interpret claims data, identify trends, and implement corrective strategies required
- Excellent communication and leadership skills with the ability to drive accountability and cross-functional collaboration required
- Strong organizational and auditing skills and attention to detail with a focus on operational efficiency and compliance integrity required
- Ability to effectively organize, prioritize, and manage multiple tasks/projects with simultaneous conflicting deadlines required
- Strong analytic, decision-making, and problem-solving abilities required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
- Demonstrated leadership skills in a matrix environment required
- Ability to discern and identify patterns/trends of issues and provide recommendations for resolution required
Additional Information
- Requisition ID: 1000003153
- Hiring Range: $77,760-$149,040
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EmblemHealth
May 21, 2026