Claims Operations Spec ITS (REMOTE)
Advantasure

SUMMARY:

The Claims Operations Specialist is responsible for ensuring the accuracy and timeliness of Medicare Advantage ITS claims processing for the BlueCard program. In this role, the Specialist will be responsible for performing, developing, analyzing and evaluating claims operational performance and processes specifically related to ITS claims. This role also requires effectively participating in discussions with staff, management, providers, internal teams and business process outsourcing vendors as well as through reporting and quality monitoring and oversight activities with the expectancy of implementing process improvement initiatives that will strengthen claims quality and performance leading to operational excellence, continuous service improvement for our customers and maintaining compliance. This role is also responsible for ongoing training of BlueSquared activities for all employees and vendors requiring such access.

RESPONSIBILITIES/TASKS:

• Work with and coordinate with other Blue partners on Global Certification.

• Answer questions on LCMP for new partner plans.
• Work with claims processor on testing and timelines of new Plan Connextion releases.
• Establish a mutual partnership with other ITS Medicare plans.
• Review and approve Provider incentives.
• Monitoring of ITS claim files uploaded in systems.
• Identify and report trends and issues detected and provide issue resolution in error processing and escalated issues.

• Conduct outbound calls and service tickets to Plan Connextion and other plans as required.
• Support and participate in system testing and requirements gathering related to operational readiness updates based on system enhancements, CMS software releases and as needed.
• Provide and implement quality and process improvement initiatives; assist in the creation and implementation of policies and procedures and workflows.
• Participate in the development and maintenance of training materials related to BlueSquared activities
• Train, as needed, employees and vendors on BlueSquared materials
• Serve as point of contact for ITS escalated issues.
• Support all CMS and internal audit activities as needed.
• Foster positive working relationships with internal and external partners with open and constructive communication.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION:

Bachelor's degree in a related field. Relevant combination of education and experience may be considered in lieu of degree. Certification or progress toward certification is highly preferred and encouraged.

EXPERIENCE:

With the proper education credentials a minimum of five years experience in a claims environment, preferably in a managed care or healthcare environment, or equivalent experience which provides the necessary skills, knowledge and abilities is required.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Knowledge of ITS claims processing.
• Knowledge of Medicare Advantage processes and Centers for Medicare & Medicaid Services (CMS) guidelines highly preferred.
• Excellent verbal and written communication and interpersonal skills.
• Strong analytical and critical thinking skills with a high attention to detail.
• Must be able to be flexible in a fast pace environment and adaptable to change.
• Ability to work independently as well as with all levels of staff, leadership and external partners and vendors.
• Ability to effectively prioritize, coordinate and lead activities.
• A strong working knowledge of Microsoft office products.

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards or remotely. 20% travel may be required as needed.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.

This job has expired.