Elite Technical Services is partnering with a major healthcare insurance provider to identify analytical and detail-oriented Medical Claims Processors to join their Coordination of Benefits (COB) operational team. This specialized track serves as a vital financial filter, ensuring claims involving members with multiple insurance policies are adjudicated accurately and in compliance with coordination rules.

This is a high-volume, production-driven environment ideal for professionals who enjoy complex research, navigating multiple coverage rules, and preventing multi-policy payment discrepancies.

Key Responsibilities:
- Review and investigate complex medical claims flagged for multiple active insurance policies to determine correct primary, secondary, or tertiary liability.
- Apply standard Coordination of Benefits (COB) rules and regulatory guidelines to establish the correct sequence of insurance responsibility.
- Utilize the Facets core claims platform to review member eligibility records, coverage terms, and historical claim structures.
- Analyze provider billing data against secondary insurance policy terms, processing adjustments or payments based on primary payor determinations.
- Identify overpayments, processing errors, or third-party liability issues, updating claimant records with clear, concise system documentation.
- Maintain high daily production targets and quality assurance metrics to ensure smooth, compliant claims throughput.

Required Skills

Qualifications & Requirements:
- HS Diploma is Required
- 3+ years of hands-on experience in medical claims processing and adjudication is strictly required, with prior experience specifically focused on Coordination of Benefits (COB) rules and workflows.
- Prior experience utilizing the Facets core claims processing platform is highly advantageous.
- Strong knowledge of healthcare insurance infrastructure, primary vs. secondary logic, and medical terminology.
- Sharp analytical and problem-solving skills with an ability to parse complex policy language.
- Proven capability to meet rigid daily production quotas and quality accuracy standards.