Coordination of Benefits Specialist

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job-it's a passion to serve and improve lives every day.

Primary Purpose

Parkland Community Health Plan's (PCHP's) Coordination of Benefits (COB) Specialist is responsible for identifying, verifying, and applying primary and secondary insurance coverage to ensure accurate claims adjudication. This role collaborates with internal teams and external stakeholders to prevent overpayments, resolve discrepancies, and maintain compliance with regulatory requirements.

Minimum Specifications

Education

* High school diploma or equivalent required.

Experience

* Two (2) years of experience in healthcare claims processing or COB-related functions.

* Experience working with QNXT or similar claims processing systems preferred.

Skills or Special Abilities

* Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.

* Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.

* Excellent analytical and problem-solving skills.

* Familiarity with coordination of benefits processes, claims adjudication, and payer rules.

* Expert knowledge of primary and secondary insurance rules, including Medicaid and TMHP regulations.

* Proficient in identifying and applying member benefit coverage information.

* Ability to analyze data to ensure accurate coordination of benefits and resolve issues efficiently.

* Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.

* Ability to write clearly and succinctly with a high level of attention to detail.

* Proficient computer and Microsoft Office skills. Ability to learn new software programs.

* Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Responsibilities

Operations

• Verify and document primary and secondary insurance coverage for members to ensure accurate claims processing.
• Proactively resolve COB-related discrepancies, preventing overpayments, and recouping from other payers.
• Ensure COB rules are properly configured in QNXT so that claims are accurately adjudicated, overpayments are minimized, and dollars are appropriately recouped from other payers in compliance with HHSC requirements.
• Ensure state COB files/reports are accurately and promptly exchanged in compliance with HHSC COB requirements.
• Regularly review and monitor vendor processes to confirm that updates and changes related to membership data are accurately implemented.
• Identify, resolve, and report on member COB discrepancies.
• Investigate and correct claims issues caused by misapplied benefit coordination.
• Maintain accurate documentation of COB determinations and resolutions.
• Work closely with claims processors, configuration teams, and providers to address COB-related questions and issues.
• Communicate COB determinations clearly to stakeholders and provide guidance on best practices.
• Generate reports to track COB activity, identify trends, and recommend process improvements.
• Establish and maintain strong working relationships with COB vendors to ensure seamless communication and collaboration.

Quality

• Integrate health literacy principles into all communication including Members and Providers.
• Support strategies that meet clinical, quality and network improvement goals.
• Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
• For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.
• Participate in team discussions to refine COB workflows and ensure efficient operations.

Regulatory

• Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.
• Ensure all COB activities comply with federal and state regulations, including HHSC contract requirements.

Professional Accountability

• Promotes and supports a culturally welcoming and inclusive work environment.
• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements.
• Attends required meetings and town halls.
• Recognizes and communicates ethical and legal concerns through the established channels of communication.
• Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Maintains confidentiality at all times.
• Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies.

Job Accountabilities

Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.

Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.

Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.