Benefits Coordination Analyst

Triple-S Management Corp.; San Juan (PR); On-site; USD 40,000 - 65,000; Full time

Job summary

Triple-S Management Corp. is seeking a detail-oriented COB claims analyst to support coordination of benefits across Medicare, Medicaid, and commercial lines. The role focuses on analyzing claims, identifying overpayments, and assembling documentation to support denials.

You will generate COB and medical claims reports, prepare defenses for Medicare Center responses, evaluate payments, and collaborate with Sales, Marketing, and Finance to ensure accurate, compliant processing.

Qualifications

• Bachelor’s Degree with 1–3 years in COB, claims evaluation or medical billing.
• Associate degree (60–64 credits) with 3–5 years in COB, claims evaluation or medical billing.
• None required for licenses/certifications.

Responsibilities

• Generate and analyze COB and medical claims data to identify overpayments.
• Prepare defense to response to Medicare Commercial Repayment Center.
• Evaluate Medicare payments related to Coordination of Benefits debts.
• Analyze pharmacy claims and internal overpayments.
• Create recovery COB adjustment petitions and reconcile data.
• Deliver Cost Avoidance reports with Sales and Marketing teams.
• Train other departments on COB end-to-end processes.
• Coordinate with CRC Supervisors on Demand Letters and liaise with Finance on CRC payments.
• Validate COB benefits in the QNXT enrollment module to ensure payment integrity.

Skills

COB analysis

Medical billing

Data analysis

Communication

Education

Bachelor's Degree

Associate's Degree

Tools

QNXT

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
• 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.