Benefits Coordination Analyst

Triple-S; Guaynabo (PR); On-site; USD 55,000 - 75,000; Full time

Job summary

Triple-S is seeking a COB/claims specialist to analyze benefits coordination claims when insured has coverage through other insurers. You will collect, present, and explain documentation supporting service denials and work to recover overpayments.

The role requires 1–5 years in COB, claims evaluation or medical billing, and a background in analyzing Medicare and related plans. Bachelor’s or Associate degrees are expected, with opportunities to train across departments.

Qualifications

• Bachelor's Degree with 1–3 years of related experience in COB, claims evaluation, or medical billing.
• Associate degree (60–64) college credits with 3–5 years of experience in COB, claims evaluation, or medical billing.

Responsibilities

• Generate and analyze COB and medical claims data to identify overpayments across Commercial, Medicare and Medicaid.
• Compile documents and prepare defense for Medicare Recovery Center responses.
• Evaluate Medicare payments related to COB debts.
• Analyze pharmacy reports and internal overpayments.
• Create COB adjustment petitions and reconcile data; deliver Cost Avoidance reports with Sales and Marketing teams.
• Review Plan Documents, COB Certification and Policies to resolve debts.
• Provide training to other departments on end-to-end COB processes.
• Coordinate with CRC Supervisors on Demand Letters and with Finance on demand checks.
• Validate COB payment integrity in the enrollment module (QNXT).

Skills

Ambiguity Management

Trust Building

Collaboration

Customer Focus

Action Oriented

Education

Bachelor's Degree

Associate's Degree

Job description

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Job Summary

Responsible for the benefits coordination claims in cases where the insured maintains benefits through other insurance companies, associations, organizations and, orentities. Analyze the claims submitted for each case and identify the services. Collect, present, and explain the documentation that supports the denial of services that qualify for payment. Analyze claims with possible overpayments for all service lines to request adjustments and or maintenance.

Essential Functions

• Generate and analyze data through COB and medical claims reports to identify Commercial, Medicare and Medicaid overpayments.
• Compile documents and prepare defense to response to Medicare Commercial Repayment Center.
• Evaluate payments for Medicare related to the debts of Coordination of Benefit claims.
• Analize pharmacy reports sent by others Plan insurances and analyze internal overpayments of pharmacy claims.
• Create recovery COB adjustment petitions, follow up and reconcile data upon completion Process, analyze and deliver the Cost Avoidance reports in collaboration with the Sales Group Associate and Marketing Department.
• Analyze Plan Documents, Certification of Benefits and Policies for the resolution of debts.
• Provide training to other departments as Member Management, Claims and Service Management to give tools for the appropriate manage of the Coordination of Benefit end to end process.
• Coordinate meeting with Commercial Repayment Center Supervisors to discuss Demand Letters. Coordinates with Finance on demand checks for CRC payments.
• Validate the quality of the coordination of benefits on QNXT enrollment module to ensure the integrity of the payment.

EDUCATION

• Bachelor's Degree
• Associate's Degree

Experience

Bachelor’s Degree with 1 to 3 years of related experience working in COB, claims evaluation or medical billing or Associate degree (60-64) college credits (AD) with (3) to (5) years of experience in COB, claims evaluation or medical billing.

LICENSES AND CERTIFICATIONS

• None required

COMPETENCIES

• Manages Ambiguity
• Instills Trust
• Collaborates
• Customer Delight (Employee)
• Action Oriented

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.