Claims Operations Specialist

Role Overview

• Responsible for ensuring timely completion of non-electronically processed claims such as direct member reimbursement claims and commercial out-of-network claims.
• Ensure claims approvals and/or denials are made in accordance with company practices and procedures. Timely execution on member communications at scale, including mail-outs through our third-party mail vendor.
• Maintain reimbursement queue to meet the department's SLA’s. Completion of assigned claim cases in accordance with daily expectations.
• Sustain integrity of all existing claims processes by ensuring all process documentation is up to date.
• Participate in process improvement and quality assurance opportunities.
• Collaborate and provide cross-functional support to account management, member support, and other customer success teams.
• Act as a liaison between the clinical team and the member for denied reimbursements, initiating the prior authorization (PA) process to ensure proactive member support.
• Participate in internal meetings to help support initiatives and projects.
• Ability to prioritize and complete high-volume cases/claims.

Requirements

• 2+ year of experience in a healthcare claims role, preferably in a pharmacy setting or licensed as a pharmacy technician.
• Prior working knowledge of medical or pharmacy claims processing.
• Excellent organization skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
• Microsoft Excel skills required.
• Impeccable attention to detail and accuracy in work.
• Strong problem solving, written and verbal communication, and interpersonal skills
• Ability to work independently as well as part of an extended, cross-functional team
• Self-driven, results-oriented work ethic with a positive outlook
• Ability to take initiative with little to no direction

Benefits

• Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life and AD&D Insurance
• 3 Weeks Paid Time Off
• Paid Company Holidays
• Paid Parental Leave Benefits
• Flexible Spending Benefits
• 401(k) Retirement Savings Program
• Short-Term and Long-Term Disability
• Wellness Benefits
• Commuter Benefits
• Employee Assistance Program (EAP)
• Well-stocked Kitchen In Office Locations
• Professional Development and Training Opportunities