Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Sr. Coordination of Benefits and Recovery Specialist
REMOTE
Summary of Position
- Responsible for leading complex COB investigations across all lines of business, including governmental and commercial products, educating and resolving the discrepancies with insurance carriers, employers and providers.
- Ensure accurate determination of payer responsibility, protect organizational revenue, and maintain compliance with federal and state regulations.
- Serve as a subject matter expert, providing guidance, training, and quality oversight to COB Specialists while supporting operational excellence, overpayment prevention, and continuous improvement initiatives.
Principal Accountabilities
- Lead and conduct complex COB investigations for Medicare, Medicaid, Essential Plan, Exchange, and Commercial Group Health Plan claims.
- Research and resolve escalated claim denials, payment discrepancies, overpayments, and recovery cases.
- Analyze policy documents, Evidence of Benefits (EOBs), eligibility records, and contractual language to accurately determine primary and secondary payer responsibility.
- Identify and validate Other Health Insurance (OHI) coverage and ensure correct application of Coordination of Benefits rules.
- Serve as a subject matter expert (SME) for governmental and commercial COB regulations, providing guidance and case consultation to COB analysts.
- Deliver training and mentorship to team members to enhance technical expertise, regulatory knowledge, and investigative effectiveness.
- Partner with external entities including CMS, Treasury Dept, Medicare Commercial Repayment Center, commercial insurers, and third-party administrators to validate coverage and resolve complex payer disputes.
- Manage CRC portal and Open Debt reports. Review internal investigation and vendor reports to ensure timeliness and accuracy.
- Monitor trends in COB errors, denials, and recoveries; recommend corrective actions and process improvements to strengthen operational efficiency.
- Support cross-functional collaboration with Claims, Enrollment, Compliance, Finance, and IT to ensure data accuracy and proper claims adjudication.
- Ensure adherence to CMS guidelines, including Medicare Secondary Payer (MSP) requirements and reporting obligations.
- Maintain compliance with federal and state Medicaid COB regulations and commercial coordination standards.
- Support internal audits, regulatory reviews, and external examinations by maintaining accurate case documentation and investigative records.
- Contribute to corrective action plans and continuous quality improvement initiatives in response to audit findings or regulatory changes.
- Participate in system testing, policy updates, and workflow enhancements related to COB processes.
- Perform other duties as assigned or required.
Qualifications
Education, Training, Licenses, Certifications
- Bachelor’s degree required; additional experience/specialized training may be considered in lieu of degree
Relevant Work Experience, Knowledge, Skills, and Abilities
- 4 – 6+ years of relevant work experience in a healthcare environment required
- Comprehensive knowledge of HIPAA regulations & CMS guidelines, including Medicare Secondary Payer (MSP) provisions required
- Strong analytical skills with the ability to interpret policy documents, EOBs, eligibility files, and regulatory requirements required
- Expertise in COB investigative methodologies, overpayment recovery processes, and denial resolution required
- Proficiency with claims processing systems such as Facets and related eligibility and enrollment platforms required
- Strong written and verbal communication skills; ability to effectively liaise with regulatory agencies and external insurers required
- Detail-oriented with a focus on operational accuracy, compliance integrity, and revenue protection required
- Ability to manage multiple complex cases simultaneously in a fast-paced environment required
- Strong analytic, decision‐making, and problem‐solving abilities required
- Strong investigative skills, with proven ability to gather and interpret Explanation of Benefits (EOB), including use of online payer portals, answer questions and resolve standard as well as complex issues with payments required
- Ability to follow policy, procedures, and regulations in the workplace, and demonstrates ability to lead by example and support development of junior team members required
- Ability to effectively perform work independently and work cooperatively with others to promote a positive team environment; effectively serve as subject matter expert, lead by example, and to contribute to team results and progress required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.