eCOB Specialist I

Solis Health Plans

About The Position

The eCOB Specialist I is responsible for researching, investigating, and maintaining accurate Other Health Insurance (OHI) and Coordination of Benefits (COB) information for members. This role ensures accurate identification of primary, secondary, and tertiary coverage by leveraging data from the Centers for Medicare & Medicaid Services (CMS) eligibility files, internal systems, and external carrier sources. The eCOB Specialist I ensures accurate COB data integrity at the time of claims processing and is responsible for updating membership records to support correct claims adjudication, financial accuracy, and compliance with CMS requirements and Medicare Secondary Payer (MSP) rules.

Requirements

High School Diploma or GED required.
Minimum of 3–5 years of experience in healthcare claims, eligibility, COB, or Medicare coordination functions.
Experience working with CMS eligibility files, Medicare Advantage, or Medicare Secondary Payer (MSP) rules preferred.
Strong understanding of insurance coordination principles and healthcare claims processing.
Equivalent combination of education and experience may be considered.
Strong investigative and analytical skills
High attention to detail and data accuracy
Ability to interpret complex coordination rules and regulatory guidance
Strong communication skills for members and carrier outreach
Ability to manage multiple research cases independently
Proficiency in documentation and system data entry
Strong problem-solving and decision-making abilities

Nice To Haves

Experience with CMS enrollment data and Medicare eligibility processes.
Familiarity with COB recovery processes and claims adjustment workflows.
Knowledge of managed care operations and multi-payer coordination.
Experience using claims or membership systems in a health plan environment.

Responsibilities

Research and investigate potential other insurance coverage for all members and employer groups using CMS eligibility files, internal systems, and external data sources.
Maintain accurate Coordination of Benefits (COB) records to ensure correct payer sequencing during claims processing.
Identify, validate, and update Medicare and other insurance coverage indicators in membership systems, including CMS-derived enrollment data.
Review CMS file discrepancies and ensure accurate reflection of primary and secondary coverage in health plan systems.
Perform end-to-end Coordination of Benefits (COB) activities, including identification, verification, and maintenance of other insurance coverage.
Reconcile membership, claims, and eligibility data to ensure consistency across systems.
Analyze claim history to identify coordination issues, overpayments, or incorrect primary payer assignments.
Apply Medicare Secondary Payer (MSP) rules and other applicable coordination guidelines to determine correct liability.
Utilize internal and external resources to identify other coverage, including proprietary tools, CMS files, and payer databases.
Conduct outbound research activities, including phone calls and written correspondence to: Other insurance carriers Members and dependents Employers and groups Providers Attorneys or third-party representatives CMS and Medicaid agencies
Assist members with understanding Medicare eligibility and enrollment requirements when applicable.
Provide guidance and appropriate documentation to support member enrollment in Medicare or other coverage when entitlement is identified.
Update membership and eligibility systems with verified COB findings.
Ensure accurate coding and configuration of primary and secondary coverage indicators in CMS-aligned records.
Maintain data integrity across all system platforms to support claims adjudication accuracy.
Identify and correct system discrepancies related to COB, eligibility, and CMS enrollment data.
Review impacted claims to ensure proper coordination based on verified COB information.
Identify claims that require reprocessing, adjustment, or recovery due to incorrect primary payer assignment.
Support claims operations by providing accurate COB data to ensure proper adjudication outcomes.
Collaborate with claims and recovery teams on coordination-related adjustments and resolutions.
Ensure all COB and eligibility activities comply with CMS Medicare regulations and Medicare Secondary Payer (MSP) requirements.
Maintain confidentiality and security of protected health information (PHI) in accordance with HIPAA and organizational policies.
Document all investigation activities, findings, and system updates in accordance with audit and compliance standards.
Maintain detailed documentation of COB investigations, including sources reviewed, outreach performed, and final determinations.
Track and report trends related to COB discrepancies, CMS file inconsistencies, and eligibility errors.
Support audit requests and regulatory reviews by providing clear and accurate records of COB activity.