HCO Operations Specialist

Blue Cross of Idaho•Meridian, ID

3d•$26 - $36

About The Position

The Operations Specialist is designed to serve as a resource for employees and management in the areas of their functional expertise. Helps ensure compliance with company policies as well as applicable state and federal regulations. We are looking for an Operations Specialist with: Required Experience: 4 years’ relevant experience, with strong preference to include previous experience in healthcare, insurance, and/or Blue Cross of Idaho operations area(s). What a day of an Operations Specialist may look like: Supports operational governance activities for utilization-related programs, including intake processes, workflow design, scheduling support, and monitoring of downstream activities Assists with operational setup, maintenance, oversight, and monitoring of clinical programs, workflows, and associated system configurations Identifies abnormal or incomplete requests, inaccurate clinical configurations, or misaligned workflows and coordinates analysis and resolution Conducts specialized research related to medical necessity determinations, program criteria, utilization workflows, or operational exceptions Coordinates research, analysis, and issue resolution across departments including Utilization Management, Care Management, Provider Relations, Claims, IT, and Compliance Communicates with internal and external clinical stakeholders to investigate, resolve, and explain clinical operations–related issues, including complex or escalated matters Supports resolution of escalated clinical concerns requiring operational, programmatic, policy, or workflow interpretation, in partnership with clinical leadership Identifies trends, gaps, or risks in clinical operations and utilization-related processes and recommends opportunities for process improvement that enhance member, provider, and clinician experience Serves as an operational resource to assist other departments in understanding and resolving clinical operations–related inquiries, transactions, or program impacts Supports electronic processing, tracking, documentation, and reporting of clinical activities in compliance with organizational policies and state and federal regulatory requirements As of the date of this posting, a good faith estimate of the current pay range is $25.55- $35.77/hour. The position is eligible for an annual incentive bonus (variable depending on company and employee performance). The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, internal equity, geography, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer. We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program. We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies. Reasonable accommodations To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Requirements

4 years’ relevant experience, with strong preference to include previous experience in healthcare, insurance, and/or Blue Cross of Idaho operations area(s)

Responsibilities

Supports operational governance activities for utilization-related programs, including intake processes, workflow design, scheduling support, and monitoring of downstream activities
Assists with operational setup, maintenance, oversight, and monitoring of clinical programs, workflows, and associated system configurations
Identifies abnormal or incomplete requests, inaccurate clinical configurations, or misaligned workflows and coordinates analysis and resolution
Conducts specialized research related to medical necessity determinations, program criteria, utilization workflows, or operational exceptions
Coordinates research, analysis, and issue resolution across departments including Utilization Management, Care Management, Provider Relations, Claims, IT, and Compliance
Communicates with internal and external clinical stakeholders to investigate, resolve, and explain clinical operations–related issues, including complex or escalated matters
Supports resolution of escalated clinical concerns requiring operational, programmatic, policy, or workflow interpretation, in partnership with clinical leadership
Identifies trends, gaps, or risks in clinical operations and utilization-related processes and recommends opportunities for process improvement that enhance member, provider, and clinician experience
Serves as an operational resource to assist other departments in understanding and resolving clinical operations–related inquiries, transactions, or program impacts
Supports electronic processing, tracking, documentation, and reporting of clinical activities in compliance with organizational policies and state and federal regulatory requirements