- Bachelor's degree and three years of relevant work experience; or equivalent combination of education and work experience
- Strong verbal and written communication skills.
- Proficiency in Microsoft Office applications, including Word, Outlook, Excel, and Power Point.
- Collect, analyze, and leverage data and feedback related to Claims to identify opportunities for enhancing business relationships. This involves direct engagement with the Vendor Management Office (VMO) and Transformation Management Office (TMO). Create reports on incidents, events, and updates regarding claims processing issues and conflicts.
- Review information to pinpoint trends, issues, and potential solutions for development and implementation, such as new products or services, contract enhancements, and system improvements to boost efficiency. Actively share critical assessments to drive collaboration and translate analysis into actionable recommendations for process enhancements.
- Drive change initiatives and assess their impact.
- Conduct continuous research to understand evolving industry needs.
- Deliver high-quality, objective analysis.
- Communicate with vendors and internal stakeholders to swiftly exchange information on claims processing updates:
- Collaborate with cross-functional teams for task completion and updates. Coordinate with HMSA departments and external partners for information exchange.
- Present analysis, recommendations, and work outcomes through professional reports and presentations. Conduct informative sessions at various organizational levels and with vendor partners to ensure consistent reporting of outcomes.
- Inform vendors of process changes to align with health plan regulations.
- Engage with experts in project planning and implementation, contribute to requirements development, budgeting, and issue resolution.
- Organize, update, and maintain all reference materials, documents, policies, and procedures related to claims to ensure accurate application of contract benefits between HMSA and Managed Service Provider(s).
- Interpret business documents, medical policies, statistical data, and compliance guidelines to uphold standards. Ensure compliance with documentation requirements and quality control measures.
- Proactively resolve conflicts and address potential issues between HMSA, customers, and service providers.
- Stay informed on current health plan regulations and Association standards.
- Execute other assigned responsibilities and tasks as needed.
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Claims Operation Specialist - Honolulu, United States - Hawaii Medical Service Association
Description
Job SummaryPay Range: $47,500 - $88,000
Note: Employees typically start within the pay range
The Claims Operation Specialist is responsible for tracking, analyzing, and resolving claims and related system issues while working closely with our vendor to streamline operational processes. In this position, the Specialist will oversee vendor compliance with Service Level Agreements, track issues, and collaborate with different departments to ensure HMSA achieves all claim goals and objectives.
Minimum Qualifications
