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Patient Financial Services COB Specialist - Rockville Regional Offices

Location: Rockville, MD Job Number: 721801 Date posted: 08/08/2018
Description: Identifies, researches and validates cases involving Medicare, other commercial carrier, Dual coverage and other third party liability situations, including researching primacy determination on complex cases involving another payor, claims cost avoidance.

Essential Functions:
  • Distributes eligibility surveys to appropriate members for the entire membership database.
  • Places primary calls to members for the entire membership database when surveys aren't returned.
  • Applies National Association of Insurance Commission (NAIC) guidelines to determine primary / secondary liabilities when required.
  • Applies Medicare Secondary Payor and, NAIC rules and regulations to determine Medicare and Commercial Primacy determination for accurate payment of benefits relative to Claims adjudication and billing.
  • Generates and analyzes applicable departmental reports, documents revenue recovery opportunities from providers, attorneys and other insurance adjusters, etc. and communicates to Claims Administration.
  • Reviews and responds to various forms of inquiries from CMS, providers, members, attorneys and other insurance personnel.
  • Manages Macess work flow queues according to Claims department policies, guidelines and turn around time.
  • Assists in the development and implementation of policies and procedures for the department and COB unit.
  • Recommend changes to management.
  • Interprets new laws and regulations in all operating jurisdictions including CMS, NAIC and federal and state.
  • Communicates changes in regulations appropriately to all interested parties.
  • Advises management of pending changes.
  • Maintains current knowledge of: covered and non-covered Medicare benefits administration and health plan benefits;Specific provder contractual arrangements; Provider Service Center processes and procedures; Appeals process; Changes in Claims processing policies and procedures.
  • Acts in the capacity of Medicare and Commercial COB subject matter specialist to several internal departments and external customers/clients.
  • Provides linkages between the departments to facilitate recovery, billing and other primacy related issues.
  • Maintains monthly reports on liens, third party and Workers Compensation questionnaires, recoupment revenue, adjustments and other related activities.
  • Performs retroactive claims payment audit for newly identified Medicare and Commercial primary members.
  • Communicates recovery opportunities to Claims Administration.
  • Maintains Medicare and Commercial primacy determinations in TPL module, HSD Diamond and PFS Billing system.
  • Performs other duties as directed.

  • Basic Qualifications:
    Experience
  • Minimum four (4) years of experience specializing in COB, Medicare, Medicaid, Dual Coverage TPL and/or Workers Compensation claims.
    Education
  • Bachelor's degree OR four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required.
    License, Certification, Registration
  • N/A

    Additional Requirements:
  • Experience in health insurance claims processing and benefits environment.
  • Working knowledge of Medicare, medical and other insurance terminology.
  • Knowledge of Medicare and other insurance products.
  • Demonstrated writing and reporting skillsDemonstrated expertise in industry practices and regulations in the tri-state area pertaining to Medicare, Workers Compensation, Dual Coverage and Subrogation.
  • Demonstrated excellent communication skills: writing, verbal and negotiating skills.
  • Can negotiate skillfully in tough situations with both internal and external customers; can win concessions without damaging relationships; can be direct and forceful as well as diplomatic; has a good sense of timing.
  • Is dedicated to meeting the expectations and requirements of internal and external customers; gets first-hand information and uses it for improvements in services and cost savings; establishes and maintains effective relationships with customers and gains their trust and respect.
  • Uses rigorous logic and methods to solve difficult problems with effective solutions; enjoys working hard; is action oriented and enjoys working in a team environment to achieve goals.

    Preferred Qualifications:
  • Minimum one (1) year in a customer service environment preferred.
  • Experience working with cross-functional teams preferred.


    Primary Location: Maryland,Rockville,Rockville Regional Offices 2101 E. Jefferson St. Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 4:30 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Individual Contributor Job Category: Administration, Clerical and Support Services Specialty: Support Services Department: Patient Financial Services Travel: No
    Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
  • About Administration, Clerical & Support Services Careers

    Administration, Clerical & Support Services Careers

    From greeting callers and visitors and answering questions to coordinating schedules and arranging meetings, our administrative, clerical, and support teams consistently demonstrate extraordinary knowledge, skills, and abilities. They provide superior and culturally sensitive service to each other, our members, purchasers, contracted providers, and vendors.

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