Claims Operations Specialist

Are you ready for new challenges and new opportunities?Join our team!AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all.The Opportunity:The Claims Operations Specialist will be responsible for the business process within the claims department such as Cost Share, Claims Recovery and Claims Resolution. This individual will provide outreach to Members, Providers, as well as work with internal departments to resolve issues in a timely manner. The Claims Operations Specialist will create/update Business Process flows, Desk Level Procedures, and Training Documents for primary work areas (Cost Share, Claim Recovery and Claim Resolution).Primary Duties and Responsibilities:Cost Share:Manages member cost share business processes including conducting member and provider outreach, generating invoice letters, adjusting claims when appropriate.Investigates and analyzes department processes and works with other departments (Enrollment, Finance and Service Coordination) to improve the recovery of cost share and processing of claims with cost share.Claims Recovery:Researches and analyzes claims data to identify potential recoveries.Investigates department processes and works with Enrollment Department to identify issues that cause claims to be recovered.Works with Enrollment Department staff to identify, resolve and reduce member eligibility related issues that cause the inaccurate processing of new claims.Works with Data Analysis staff to develop recovery identification and monitoring reports.Works with Business Support Service staff to modify claims adjudication processes that cause the inaccurate processing of new claims.Performs claim adjustments as required.Researches and analyzes claims data to identify potential issues that cause the inaccurate processing of claims which impact providers.Responds to Provider Inquires through either written or verbal communication.Investigates department processes and works with other departments such as Credentialing, Contracting, Customer Service, Provider Relations, and Enrollment to identify issues that result in the inaccurate processing of claims.Works with Data Analysis staff to develop claim denial monitoring reports.Performs claim adjustments as required.Other Duties and Responsibilities:Reviews Medicare, State and Federal Correspondence to advise Claims Management staff of requirement changes that could impact business processes.Assists with documenting business requirements for configuration changes.Performs verification or screening of EPSDT documents.Reviews business processes for opportunities for improvement and provides recommendations.Conducts system/upgrade testing as needed.Fosters collaborative relationships with internal customers.Reviews claims reporting data to identify trends and track Claims KPIs.Supports Internal Claims Audit Processes.Assists with new hire Trainings and onboarding.Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality.Requirements:High school diploma or equivalent.Minimum of two years of claims processing experience and/or equivalent combination of education, experience, and credentialing.Excellent verbal and written communication skills required.Excellent attendance; must be punctual and reliable.Experience in operation of general office equipment to include PC, fax/copy machine and ACD Mitel Phones.Intermediate skill using Microsoft Programs; Word, Excel, and Outlook.Must have the ability to read, analyze, and interpret business documents such as Claims workflows, Medical Policies, Medicare, and Medicaid Guidelines.Ability to perform advanced claims research, problem identification and claims resolution.Possess an in-depth knowledge of CPT, ICD-10, HCPCS, UB04 form, and CMS-1500 forms as they relate to insurance payment to meet Health care insurance and medical coding, billing, and payment guidelines.Preferred Requirements:Bachelor’s Degree: Business Administration, Accounting, or related field.Previous experience with Medical Claims Processing or Billing.Previous experience with QNXT.Previous experience with Medicaid or Medicare program.Health care industry experience within managed care, hospital, medical office or equivalent.Collections or payment recoveries experience.Working knowledge of SQL Server Management Studio or other similar reporting product.Mental, Physical and Environmental Demands:Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects.Inside working conditions.Requires operation of general office equipment to include PC.Salary Range: $19.75 - $26.00 an hour.AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws.

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