Financial Operations Recovery Specialist II - Carelon Coordination of Benefits

Anticipated End Date:

2025-09-23

Position Title:

Financial Operations Recovery Specialist II - Carelon Coordination of Benefits

Job Description:

Be Part of an Extraordinary Team

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

Title: Financial Operations Recovery Specialist II

Location: This role enables associates to work virtually full-time, with the exception of 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.

The Financial Operations Recovery Specialist II is responsible for the discovery, validation, recovery, and adjustments of claims overpayments. May do all or some of the following in relation to cash receipts, cash application, claim audits collections, overpayment vendor validation, and claim adjustments.

This position 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.

How you will make an impact:

• 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.

• Maintain compliance with vendor SLAs, state and federal guidelines, and employer group contracts.

• Audits paid claims for overpayments using various techniques including systems-based queries, specialized reporting, or other research.

• Responsible for more complex issues such as coordination of benefits, Medicare, and medical policies.

• Works closely with staff from other departments on a regular basis to ensure customer satisfaction.

• Works closely with contract managers to identify and correct contractual issues when applicable.

• May perform collection activities to ensure the recovery of overpayments and maintenance of unprocessed cash and accounts receivable processes and all other cash applications as required.

• Researches voluntary refunds for accuracy.

• Requires accurate balancing of all accounts.

Minimum 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.

Preferred Skills, Capabilities and Experiences:

• 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.

Job Level:

Non-Management Non-Exempt

Workshift:

1st Shift (United States of America)

Job Family:

AFA > Financial Operations

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elev