Operations Specialist III
Job Description:
- Provide analytical support and leadership for key Claims-related projects
- Regulatory reporting such as CMS and Medicaid
- Serve as high dollar claims reviewer
- Identify payment integrity issues with claims reimbursement methodologies
- Prepare and deliver responses to legal correspondence and state complaints
- Provide Claims Subject Matter Expertise (SME) for cross-functional meetings including operational and new business implementation
- Act as primary Claims Representative and SME for corporate projects
- Act as primary Claims Representative on external audits
- Assist in development of policies and procedures for claims processing, COB, appeals and adjustment functions
- Lead Claims initiatives such as working with IT and others to automate claim functions; improve front end paper claim process; and report development with SIS
- Contribute to and/or develop user stories or provide user story guidance for sprint planning
- Implement new business including the design, testing and delivery of supporting processes to the business
- Perform any other job related instructions, as requested
Requirements:
- Bachelor’s degree or equivalent years of relevant work experience required
- Minimum of five (5) years of healthcare claims environment, equivalent managed care, healthcare operations or professional industry experience is required
- Advanced proficiency level experience in Microsoft Word, Excel and PowerPoint
- Data analysis and trending skills
- Work with accumulators
- Demonstrated understanding of claims operations specifically related to managed care
- Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
Benefits:
- Comprehensive total rewards package
- Potential for bonuses tied to company and individual performance