Coordination of Benefits Representative

:

Coordination of Benefits Representative

- (3257144)

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.

We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.

The Coordination of Benefits Representative will be responsible for investigating potential recoveries for COB through phone calls, questionnaires, claims, provider inquiries, and other systems as required. This person will also be responsible for management of communications with internal and external customers, and high level of research work related to coordination of benefits opportunities. Deals directly with providers, members, CMS and other health plans in state and nationally regarding laws and statutes governing COB.

ESSENTIAL FUNCTIONS

• Responsible for identifying recovery opportunities within the COB/TPL Department.
• Review, research and process all COB claims for members with other insurance, including retractions and repayments according to desktop procedures, contractual requirements and other regulatory rules.
• Responsible for reprocessing claims for COB termed members and ensure information is added and maintained accurately in QNXT.
• Process and log all recoveries received from outside insurance companies.
• Responsible for phone calls to or from members, providers, and other insurance companies to gather or provide coordination of benefits data.
• Responsible for reviewing, researching and resolving email inquiries from internal customers regarding member's claims and/or eligibility updates.
• Responsible for researching Medicare benefits questions and guidelines to assist providers and members in claim processing. Demonstrate and apply knowledge of Medicare and CMS processes and procedures.
• Responsible for reviewing, researching and resolving Medicare Secondary Payer (MSP) cases according to Medicare guidelines and procedures. Actively communicate case status to group and Sales Team when needed.
• Coordinate recoveries per federal regulations with other insurers for services unable to be recovered.
• Validate and process MassHealth and vendors' monthly reports to identify COB claims.
• Maintain and update accurate COB information in QNXT for reporting to MassHealth and other customers as needed.
• Responsible for processing COB correspondence via mail or faxes.
• Work in collaboration with the Compliance Department at MGB Health Plan to ensure recoveries are received timely.
• Process COB questionnaires to members and make determination of primary insurance in accordance with federal and state mandates.
• Process Credit Balance claims, refunds checks, and validate claims retractions.
• Responsible for reviewing projects or reports of members with other insurances. This includes flagging members with COB information.
• Meets monthly and quality claims processing production metrics as well as quality assurance metrics established in the department.
• Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.

• Other duties as assigned with or without accommodation.

KNOWLEDGE AND EDUCATION

Required:

• High School diploma or GED is required.

Preferred/Desired:

• Associate's Degree or the equivalent combination of training and experience is preferred.
• Knowledge in working with third party payors.
• Knowledge of the MSP process.

EXPERIENCE

Required:

• 2-4 years of related experience in the COB/TPL or other HealthCare related field.
• Must be proficient in Microsoft Word, and Excel.
• Proficient PC skills including familiarity with Microsoft Access.

Preferred/Desired:

• Knowledge of ICD-9, CPT & HCPC coding or equivalent experience.

SKILLS/COMPETENCIES

• The successful candidate will possess strong customer service skills, knowledge of medical terminology, excellent communication skills, and be able to multi-task and prioritize. In addition, you must have problem solving skills and be highly organized.
• Demonstrates MGB Health Plan Core Values of Service Excellence, Quality Care, Diversity, Responsibility and Relationships.
• Respects the talent and unique contribution of every individual, culture and ethnic group and treats all people in a fair and equitable manner.
• Exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Accountable for delivering high quality work.

OTHER SKILLS

• Negotiation and conflict resolution skills

EEO Statement

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under the law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.

Primary Location MA-Somerville-MGB Health Plan at Assembly Row Work Locations MGB Health Plan at Assembly Row 399 Revolution Drive Somerville 02145 Job Admin/Clerical/CustService-Other Organization Mass General Brigham Health Plan Schedule Full-time Standard Hours 40 Shift Day Job Employee Status Regular Recruiting Department MGB Health Plan COB/TPL & Admin Services Job Posting Dec 14, 2025