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Carelon Coordination of Benefits (COB) - Investigator II

Internal Job 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.

**Carelon Payment Integrity** , an integral part of the Elevance Health family, and become a key player in transforming healthcare spending. As a member of our extraordinary team, you will help recover, eliminate, and prevent unnecessary medical expenses, making a significant impact on our mission.

The **Carelon COB Investigator II (** Financial Operations Recovery Specialist II) 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. This position mandates proficiency in multi-system data analysis, claims adjudication, and regulatory compliance, handling complex cases beyond automated systems.

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.

+ Navigate and adapt to multiple internal and external client systems with varying claims processing methodologies and requirements.

+ Initiate and manage sensitive communications with stakeholders including insurance carriers, members, providers, attorneys, CMS, and Medicaid.

+ Ensure accuracy in membership data updates, enabling correct future claims processing.

+ Apply client-specific COB methodologies for appropriate claims adjudication and payment reconciliation.

+ Identify and rectify incorrectly paid claims, ensuring precise adjustments, reprocessing, and refund recovery.

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

+ Perform additional duties as necessary to support vendor operations and client services.

• **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 and Qualifications:

+ 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 degreein 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.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.