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
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• 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
Apply tot his job
Apply To this Job