Clinical Operations Specialist
About The Position
The Clinical Operations Specialist performs routine administrative workflow tasks supporting Clinical Operations, engages and educates members and providers about G.E.H.A. benefits and programs, and identifies cases for internal and external clinical programs. The role coordinates and reviews claims, investigates medical necessity and appropriateness of care, interprets medical review results in relation to contract provisions, and supports care and cost management. This is a remote opportunity, with a requirement to reside in the Kansas City metropolitan area and meet specified home-office internet and privacy requirements.
Requirements
- Two years of college (60 credit hours) or two years of healthcare experience; additional qualifying work experience may be considered in lieu of formal education.
- Intermediate proficiency with technology applications and systems.
- Experience using Microsoft Office products, including Outlook, Excel, Word, and Teams.
- Effective written and verbal communication skills.
- Must reside in the Kansas City metropolitan area.
- Must provide non-cellular high-speed internet service, such as fiber, DSL, or cable modem, with minimum speeds of 30 Mbps download and 5 Mbps upload and latency below 80 ms. Hotspots, satellite, and wireless internet service are not allowed.
- Must have a dedicated home-office space without ongoing interruptions to protect member PHI/HIPAA information.
Responsibilities
- Use communication methods to identify and solicit information from providers and vendors according to clinical and business needs.
- Coordinate, review, and investigate claims to determine medical necessity and appropriateness of care.
- Determine which simple cases require review by a Medical Director, Pharmacist, or nurse.
- Interpret medical review results to determine compliance with contract provisions.
- Report suspected compliance, clinical, quality, and regulatory concerns.
- Identify cases for care and cost management.
- Recommend benefit allowances aligned with contract liabilities.
- Communicate with and respond to internal and external customers regarding care management, products, and services.
- Direct the processing of contractual benefits after an investigation is complete.
- Escalate complex cases to a senior team member.
- Engage and educate members and providers about G.E.H.A. benefits and programs.
Benefits
- Competitive pay/salary ranges
- Incentive plan
- Health, vision, and dental benefits effective day one
- 401(k) retirement plan with dollar-for-dollar company match up to 4% employee contribution, plus a 6% annual company contribution
- Employee well-being program
- Paid Time Off
- Personal Community Enrichment Time
- Company-provided Basic Life and AD&D
- Company-provided Short-Term and Long-Term Disability
- Tuition Assistance Program
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
