Carelon Coordination of Benefits (COB) - Investigator II

Elevance Health•Indianapolis, IN

3d•Remote

About The Position

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate, and prevent unnecessary medical-expense spending. The Carelon COB Investigator II (Financial Operations Recovery Specialist II) is tasked with conducting thorough investigations into potential other coverages, accurately determining primacy, and ensuring seamless coordination of benefits (COB) across multiple vendor clients, employer groups, and government and specialty lines of business. This position mandates proficiency in multi-system data analysis, claims adjudication, and regulatory compliance, handling complex cases beyond automated systems. This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Requirements

Requires a H.S. diploma or equivalent and a minimum of 2 years of claims processing and/or customer service experience; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

At least 2 years of experience in claims processing and customer service highly desired.
2 years of COB investigation experience is desired, with strong understanding and application of Medicare Secondary Payer (MSP), NAIC guidelines, ERISA, and other relevant regulations.
AA/AS or higher level degree in healthcare administration or insurance is preferred.
Proficiency in Microsoft Office Suite, specifically Excel, Word, Outlook, and Teams; experience with claims processing software and SQL/data analysis tools is preferred.
Expertise in Advanced Negotiation & Dispute Resolution, particularly in handling COB appeals and coverage disputes.
Self-motivated with the ability to prioritize and manage high-volume caseloads, adhering to strict SLAs.
Strong team collaboration skills, capable of working effectively within a cross-functional team while also independently managing investigations.
Exceptional attention to detail to ensure claim adjudication accuracy, membership updates, and compliance with documentation standards.

Responsibilities

Conduct in-depth COB investigations to establish primary and secondary coverage, utilizing NAIC, CMS, MSP, ERISA, and other federal and state regulations.
Analyze comprehensive data sources such as COB Smart, HEW, claims, and membership data to verify coverage and resolve discrepancies.
Navigate and adapt to multiple internal and external client systems with varying claims processing methodologies and requirements.
Initiate and manage sensitive communications with stakeholders including insurance carriers, members, providers, attorneys, CMS, and Medicaid.
Ensure accuracy in membership data updates, enabling correct future claims processing.
Apply client-specific COB methodologies for appropriate claims adjudication and payment reconciliation.
Identify and rectify incorrectly paid claims, ensuring precise adjustments, reprocessing, and refund recovery.
Maintain compliance with vendor SLAs, state and federal guidelines, and employer group contracts.
Perform additional duties as necessary to support vendor operations and client services.