Operations Specialist II (Hybrid)
About The Position
The Operations Specialist II provides analytical support and leadership for projects impacting Claims and key internal Claims projects. This role involves representing claims on cross-functional project teams, managing IT tickets, reviewing special projects to identify trends and resolutions, and assisting with reporting and process documentation. The specialist will also be involved in training claims staff and business partners, researching and resolving provider claim issues by analyzing system configuration, payment policy, and claims data. Additionally, they will perform analysis of claims data to support management decisions, identify and quantify data issues, and assist in developing resolution plans. If part of the Research and Resolution team, responsibilities include representing the Claims Department in provider interactions, providing feedback, and managing provider issues using Facets and Onbase. The role also contributes to claims business requirements, testing, and implementation tasks.
Requirements
- Bachelor’s degree or equivalent years of relevant work experience required
- Minimum of two (2) years of healthcare claims environment is required
- Advanced level experience in Microsoft Word, Excel and PowerPoint
- Data analysis and trending skills
- 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
- Ability to work independently and within a team environment
- Attention to detail
- Familiarity of the healthcare field
- Critical listening and thinking skills
- Negotiation skills/experience
- Strong interpersonal skills
- Proper grammar usage
- Technical writing skills
- Time management skills
- Strong communication skills, both written and verbal
- Customer service orientation
- Decision making/problem solving skills
Nice To Haves
- Fostering a Collaborative Workplace Culture
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
Responsibilities
- Represent claims on cross-functional project work teams
- Submit, monitor and prioritize IT tickets for the Claims department
- Review special projects and identify issue trends and potential resolutions
- Assist with Onbase reporting and processes
- Develop and draft P&P’s and job aides for Claims
- Assist in training claims staff on claims processing policy and procedures
- Assist in educating/training Business Partners on claims functions
- Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data
- Perform analysis of all claims data in order to provide decision support to Claims management team
- Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
- Represent Claims Department at requested provider calls and visits (if assigned to Research and Resolution team)
- Provide feedback and/or face-to-face interaction with providers for claims research and resolution (if assigned to Research and Resolution team)
- Responsible for research and resolution of claims issues for all assigned provider inquiries and submissions (if assigned to Research and Resolution team)
- Responsible for managing provider issues adhering to Workflow processes and tools (Facets and Onbase) (if assigned to Research and Resolution team)
- Provide input for claims business requirements, testing processes and implementation tasks and plans
- Perform any other job related instructions, as requested
Benefits
- bonus tied to company and individual performance
- substantial and comprehensive total rewards package
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
