POSITION SUMMARY

Community Health Options’ Third Party Liability (TPL) & Appeals Senior Specialist is a senior claims and recovery professional who ensures that eligible members receive benefits while recovering costs from responsible third parties, balancing legal compliance, regulatory knowledge, and operational efficiency. TPL case experience, appeals handling, compliance knowledge, and ability to manage complex third-party recovery processes. Serves as the business lead/SME for vendors performing auditing, including subrogation and coordination of benefits. Third Party Liability & Appeals Senior Specialist supports claims processes via Medical Claims through Third Party Administrators (TPAs) and Pharmacy Claims through Pharmacy Benefit Managers (PBMs) and/or Claim Business Process Outsourcing (BPO) vendors.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

Appeals

• Maintains subject matter expertise for all lines of business (LOB) regarding Member Benefit Agreement and Community Health Options Notification/Authorization requirements, claim processing policies and documentation standards that comply with regulatory requirements, accreditation standards and adherence to best practice.
• Maintains strong working knowledge and demonstrated ability to apply Community Health Option’s policies, Federal and State requirements, National Committee for Quality Assurance (NCQA) Health Plan standards, NCCI, NAIC, and CMS guidelines related to claim processing.
• Supports Manager in writing/reviewing Appeal letter language to ensure adherence to documentation requirements and timely processing in accordance with NCQA standards and State regulations.
• Supports processing appeals in accordance with established standards and workflow.
• Generates reports, monitors and addresses trends identified within appeals and reconsiderations received.
• Demonstrated attention to detail in ensuring timeliness, accuracy and completion of all documentation requirements related to denial and appeal letters and supporting documentation.
• Maintains confidentiality in all aspects of Member, Community Health Options people, and company information.
• Supports in development and enhancements to appeals platforms, workflows, and other related claims platforms and workflows.
• Any other project work or supportive duties as assigned.

Subrogation and Coordination of Benefits:

• Oversees subrogation settlement negotiations, necessary claims reprocessing, and member account configuration
• Delivers monthly reports to Senior Management and the Controller on subrogation negotiations and settlements
• Reviews all subrogation referrals and directs to the subrogation vendor as necessary
• Oversees all COB investigations, documentation, determination of primacy and resulting member account modifications and claims reprocessing

JOB SPECIFIC KEY COMPETENCIES (KSAs)

• Advanced skills in medical terminology, CPT/ICD-10 coding.
• Demonstrates strong analytical thinking and problem-solving skills.
• Strong interpersonal skills, including professional communication, relationship building, and effective written and verbal communication
• Exhibits professionalism and delivers superb customer service through all interactions and correspondence.
• Solid understanding of standard claims processing systems, operations, and claims data analysis
• Knowledge of HIPAA privacy regulation and rules necessary
• Proficiency with Microsoft Office Suite applications

DIVERSITY, EQUITY, AND INCLUSION STATEMENT

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS AND CORE REQUIREMENTS

• Bachelor's Degree in healthcare or related field, preferred
• Health Plan appeal experience, preferred
• 8+ years of experience in claims, insurance, or TPL recovery; workers’ compensation, coordination of benefits, and subrogation
• Certification Revenue Cycle Representative (CRCR), a plus
• Strong attention to detail with the ability to manage multiple priorities

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