TPL Analyst (Health Alliance Plan) - Flint, MI
Responsible for using various methods to investigate, verify, and record Coordination of Benefits (COB) and Third-Party Liability (TPL) coverage information on behalf of the HAP membership. Maintain accurate COB / TPL coverage information to trigger appropriate cost-avoidance and recovery activities.
PRINCIPAL DUTIES AND RESPONSIBILTIES:
- Evaluate COB/TPL claims and/or inquiries received from internal and external customers, including contracted vendors. Establish, update and maintain coordination records within the Core Processing System. Make accurate coordination determinations, process claims in accordance to HAP divisional processing policy, and provide timely and complete responses to customer inquiries.
- Initiate or respond to direct communication with other insurance companies, State Agencies, external parties, providers and members to obtain and/or validate other coverage.
- Maintain knowledge of all COB and liability coordination rules, including but not limited to; commercial, government, workers comp, home owners, business owners and auto insurance.
- Analyze claims data to identify accident injury triggers, coordinate appropriate follow up with external parties as applicable, update member records within the Core Processing system and recover claim overpayments. Initiate any repayment obligations when applicable.
- Research legal lien letters and respond according to established policy.
- Update member eligibility records within Core Processing System with required notes and apply applicable warning messages or hold criteria to initiate pre-payment claim review.
- Initiate and maintain various reports related to recovery and/or savings.
- Serve as a resource to team members and management in investigating potential claim errors, to determine root causes, and respond to related inquiries.
- Assist with special projects and divisional initiatives as assigned.
- Perform other related duties as assigned
- High school diploma or equivalent required. Associate's Degree preferred.
- One (1) year of experience in one of the following areas: processing COB/TPL secondary claims, auditing secondary claims for payment accuracy and/or recovery opportunity, or investigating secondary claims for payment resolution.
- Two (2) years of experience in one of the following areas: HAP claims adjudication, HAP membership eligibility maintenance including COB data, HAP secondary claims billing, or HAP record maintenance including COB determination.
- Three (3) years of experience resolving/processing provider/member inquiry cases preferred.
- Experience with Cognos query and reporting preferred.
- Two (2) years' work experience using Microsoft Word and Excel is required.
- Knowledge of COB determinants and familiarity with related laws, regulations and guidelines.
- Demonstrated competency writing business letters and appropriate use of basic language and grammar
- Basic medical terminology.
Equal Employment Opportunity/Affirmative Action Employer