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Coordination of Benefits Specialist III

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Kaiser Permanente

Jan 12

Applications are closed

  • Job
    Full-time
    Senior Level
  • Healthcare
  • Rancho Cucamonga

Requirements

  • Minimum six (6) years of experience in Healthcare, Healthcare Operations, Insurance, Finance, or a directly related field OR Bachelors degree in Healthcare, Business, Insurance, Finance, Nursing, or related field AND minimum three (3) years of experience in Healthcare, Healthcare Operations, Insurance, Finance, or a directly related field.
  • Knowledge, Skills, and Abilities (KSAs): Confidentiality; Member Service; Interpersonal Skills; Legal And Regulatory Requirements; Time Management; Adaptability; Autonomy; Organizational Skills; Microsoft Office

Responsibilities

  • Provides member outreach activities with some guidance. Serves as a liaison and resource for other coverage information (OCI) and coordination of benefits (COB) matters. Conducts research and resolution of termination and change requests for OCI. Contributes to determination and coverage updates to identify primary, secondary, and tertiary coverages. Independently records OCI/COB information and notes into necessary software. Provides production data analysis and some initial analysis to support reporting. Maintains comprehensive foundational knowledge of current laws, regulations, and departmental procedures. Applies operational policies throughout their work. Follows broad guidance to identify areas where claims are being coordinated incorrectly. Without significant guidance, investigates member coverage and/or claims/cases to determine outside payers benefits. Processes and/or assesses COB claim/cases under minimal supervision. Identifies claim/cases that are COB-related. Analyzes problem claims/cases, helping implement solutions, and follows up on their implementation. Coordinates and involves relevant stakeholders. Supports the resolution of escalated inquiries related to OCI. Supports audit processes.
  • Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.
  • Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.
  • Assesses claims/cases in support of COB by: following broad guidance to identify areas where claims/cases are being coordinated incorrectly by reviewing information available from all sources; without significant guidance, investigating member coverage and/or claims/cases to determine amount of outside payers benefits; under minimal supervision, contributing to processing/assessment of COB claims/cases for timely reimbursement; and, under minimal supervision, reviewing pending and finalized claims/cases to identify those that are COB-related.
  • Contributes to cross-group coordination by: with some guidance, providing member outreach activities, such as preparing and/or sending questionnaires to members and conducting outreach calls to other insurance carriers or members; serving as a liaison and resource using comprehensive foundational knowledge of other coverage information (OCI)/coordination of benefits (COB) for matters between the organization, members, and outside providers; conducting the research and resolution of termination and change requests for OCI, with some guidance; identifying training needs for key stakeholders throughout the organization, based on some direction; with some support, providing documentation of industry standards, Medicare guidelines, or other relevant materials for rendering decisions on medical policies or benefits; and contributing to determination and coverage updates to identify primary, secondary, and tertiary coverages.
  • Documents and reports on COB processes by: independently recording OCI/COB information and notes to enter them into all necessary software programs, with periodic supervisor/manager review of work; providing production data and conducting some initial analysis in support of report development, based on broad guidelines; maintaining comprehensive foundational knowledge of new and existing case and/or administrative law, benefit administration throughout systems and departments, and changes to regulations and requirements; and incorporating and applying new and updated internal operational policies and procedures into their work.
  • Investigates inquiries and issues related to COB by: analyzing problem claims/cases and assisting with implementation of solutions; coordinating with and involving relevant stakeholders when researching and resolving issues; applying standard strategies when following up on implementation of recommendations; independently contributing to inquiries into covered spouse and dependent health coverage; using comprehensive foundational knowledge to support resolution of inquiries related to OCI; and supporting audit processes by coordinating with audit stakeholders and documenting the process and results.

FAQs

What is the primary responsibility of a Coordination of Benefits Specialist III?

The primary responsibility is to conduct member outreach activities and serve as a liaison for coordination of benefits (COB) and other coverage information (OCI) matters, as well as to manage and resolve coverage-related inquiries.

What are the essential functions of this position?

Key functions include assessing claims, providing member outreach, documenting COB processes, investigating inquiries related to COB, and coordinating with relevant stakeholders.

What qualifications are required for this position?

A minimum of six years of experience in Healthcare, Healthcare Operations, Insurance, Finance, or a related field is required, or a Bachelor's degree in a relevant field along with a minimum of three years of experience.

What skills are necessary for this role?

Necessary skills include confidentiality, member service, interpersonal skills, knowledge of legal and regulatory requirements, time management, adaptability, autonomy, organizational skills, and proficiency in Microsoft Office.

What are the working hours for this position?

The working hours are from 08:00 AM to 05:00 PM, Monday through Friday.

Is there a possibility for career advancement in this role?

Yes, opportunities for promotion may arise as the specialist develops expertise and contributes significantly to the team.

What type of employment is this position?

This position is full-time with a standard employee status.

Is travel required for this position?

No, this position does not require travel.

What additional support is provided for team members in this role?

The specialist is expected to mentor team members and provide resources and expertise to support their development.

What organizational department is this position part of?

This position is part of the Englewood MSSA Claims - National Claims Service Org - 0315 department.

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Kaiser Permanente

Science & Healthcare
Industry
10,001+
Employees
1945
Founded Year

Mission & Purpose

We are relentless in our pursuit of excellence. Founded nearly 80 years ago, our unique business model sets us apart — positioning us to drive improvements across the industry and around the world. k-p.li/aboutKP As the nation’s leading not-for-profit health plan, we proudly serve 12.7 million members from 600+ locations in 8 states and Washington, D.C. Together, our 200,000+ employees and physicians work as one to positively impact the lives of our members, employees, and communities. Come drive quality, inspire excellence, and create change for the better. Bring your talents to Kaiser Permanente, and see your visionary ideas make a difference in the lives of others. This is your opportunity to shape the future of health care. Be essential. *Disclaimer: Please do not include any medical, personal or confidential information in your comments. Comments are encouraged; however, Kaiser Permanente reserves the right to moderate comments on this page as necessary to prevent medical, personal and confidential information from being posted on this site. In addition, Kaiser Permanente will remove all spam, personal attacks, profanity, and off-topic commentary. Comments containing advertisements about goods or services or announcements about news or events that are not related to Kaiser Permanente will be removed. Please note that your communications with Kaiser Permanente through this page are informal and are not part of Kaiser Permanente’s formal grievance process for members.