Provide analytical support and leadership for key Claims-related projects
Regulatory reporting such as CMS and Medicaid
Serve as high dollar claims reviewer
Identify payment integrity issues with claims reimbursement methodologies
Prepare and deliver responses to legal correspondence and state complaints
Provide Claims Subject Matter Expertise (SME) for cross-functional meetings including operational and new business implementation
Act as primary Claims Representative and SME for corporate projects
Act as primary Claims Representative on external audits
Assist in development of policies and procedures for claims processing, COB, appeals and adjustment functions
Lead Claims initiatives such as working with IT and others to automate claim functions; improve front end paper claim process; and report development with SIS
Contribute to and/or develop user stories or provide user story guidance for sprint planning
Implement new business including the design, testing and delivery of supporting processes to the business
Perform any other job related instructions, as requested

Bachelor’s degree or equivalent years of relevant work experience required
Minimum of five (5) years of healthcare claims environment, equivalent managed care, healthcare operations or professional industry experience is required
Advanced proficiency level experience in Microsoft Word, Excel and PowerPoint
Data analysis and trending skills
Work with accumulators
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

Operations Specialist III

Key skills