POSITION SUMMARY/ /

　　Responsible for reviewing claims based on provider and health plan contractual agreements and claims processing guidelines to ensure accurate payment where Coordination of Benefits (COB), Third Party Liability (TPL), Medicare Secondary Payer (MSP) or Subrogation guidelines apply. Support Health Plan Operations in its relationship with vendor partners by ensuring claim payment is compliant with operational and regulatory guidelines. Oversee HFHP guidelines, policies and procedures and desktop processes for alignment where COB, TPL and/or legal settlements may apply.

　　PRIMARY ACCOUNTABILITIES//

　　Leverage knowledge and expertise in COB, TPL, MSP and/or Subrogation to review eligibility, investigate the policy coverage to determine proper order of benefits and answer questions and/or provide guidance for accurate claim payment or other appropriate action.

　　Communicate professionally and effectively with providers, Health Insurance carriers, beneficiaries, vendors and other audiences regarding eligibility, COB, TPL, MSP and/or Subrogation rules.

　　Gather and interpret Explanation of Benefits (EOB) to answer questions and resolve primary, secondary or tertiary payment issues.

　　Ensure claims are paid correctly by identifying health benefits available, coordinating the payment process to ensure the order of benefits applied (primary/secondary/tertiary) is accurate and appropriate, and ensuring that the primary payer, whether Medicare or other insurance, pays first.

　　Ensure the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate payments.

　　Utilize resources to ensure compliance with requirements, HIPAA and applicable federal or state regulations related to COB, TPL, MSP and/or Subrogation questions for accurate claims payment in a timely manner.

　　Act as a training resource for other associates, providing accurate direction regarding COB, TPL, MSP or Subrogation related items and system applications.

　　Respond to subpoenas, letters, or other correspondence from attorneys, asserting Subrogation rights/rights of recovery and presenting lien within required timeframes, as requested.

　　Primary liaison between HFHP and Subrogation vendor, responding to correspondence within a timely manner and notifying vendor of potential Subrogation cases for review.

　　10.Prioritize work to support the general operations and on-going success of the organization.

　　Audit Health Plan claim data for overpayments using reporting or other research, ensuring overpayment requests are issued where appropriate.MINIMUM QUALIFICATIONS/ /• Education:High school.• Licensure:None• Certification:None• Work Experience: o 2 years claims processing experience with a focus area of Coordination of Benefits and overpayment identification.• Knowledge/Skills/Abilities:

　　o Strong knowledge and proficiency in health care claims processing, medical benefits, medical terminology.o Experience with Coordination of Benefits, Third Party Liability and Subrogation.o Possess understanding of Centers for Medicare and Medicaid Services (CMS) and National Association of Insurance Commissioners (NAIC) guidelines.o Excellent interpersonal, written and oral presentation skills.o Proficient in Microsoft applications. o Ability to build relationships with internal/external departments.o Ability to effectively perform work independently and work cooperatively with others to promote a positive team environment.o Excellent skills in performing comprehensive research and analysis.* *PREFERRED QUALIFICATIONS/ /• Education:Associates degree inBusiness Administration, Health Services Administration or related field• Licensure:No additional required• Certification:No additional required• Work Experience:Experience in healthcare claims processing• Knowledge/Skills/Abilities:Advanced level proficiency with Microsoft applications.** **PHYSICAL REQUIREMENTS/ /• Majority of time involves sitting or standing; occasional walking, bending, stooping

　　• Long periods of computer time or at workstation• Light work that may include lifting or moving objects up to 20 pounds with or without assistance. • May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise

　　• Communicating with others to exchange information. • Visual acuity and hand-eye coordination to perform tasks • Workspace may vary from open to confined; on site or remote • May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle

　　Job: *Operations

　　Organization: *HF Administrative Plan Inc

　　Title: Payment Integrity Coordinator - Payment Integrity

　　Location: Florida - Brevard County-Melbourne

　　Requisition ID: 070661