Claims Operations Specialist
Posted on: November 24, 2022
- Assists with collecting, analyzing, and utilizing data and
feedback related to Claims to identify opportunities to improve the
relationship between the business and the other entity. This will
include direct communication and participation with the Vendor
Management Office (VMO) and Transformation Management Office (TMO).
Compile reports about incidents, events, and updates regarding
claims processing issues and conflicts
- Gathers, reviews, and analyzes information to identify trends,
issues, and potential problems and solutions related to development
and implementation, including but not limited to new products or
services, contract deliverables, enhancements to add functionality
and/or redesigns of systems, both manual and automated, to improve
efficiency, financial models of costing and pricing. This includes
reviewing and validating new implementations.
- Initiates in the development of strategies and tactics based on
logical assumptions and facts considering resources, constraints,
and HMSA values. Provides critical assessments of information and
data about current trends and issues and actively and openly shares
with appropriate parties to encourage collaboration for improvement
and change. Translates analysis into solutions and/or options for
consideration of specific HMSA actions, including business process
- Initiate change and evaluate impact.
- Conducts ongoing research and analysis to assess changing needs
of our industry.
- Provides quality, objective, and professional analysis.
- Assists in communicating with vendor and internal stakeholders
to quickly and accurately obtain or provide information regarding
claims processing updates:
- Works directly with cross-departmental team members to complete
tasks and provide status updates. Works with HMSA departments and
external partners to monitor, collect, communicate, and distribute
- Communicates analysis, assessments, recommendations and
completed work product through professional written and verbal
reports and presentations. Conducts presentations to all levels of
the organization (unit meetings, department meetings, management
meetings, etc.) and our vendor partner to ensure reporting of
quality outcomes are consistent and understood.
- Communicate process changes to vendor to stay current with
government and commercial health plans, agencies, and other
- Engages and collaborates with staff and subject matter experts
with the planning and implementation of project and sub project
work efforts. Supplies or advises in the development of
requirements, reports, budgets, and other analysis, and help solve
operational issues and roadblocks.
- Assists with organizing, maintaining, and keeping readily
accessible, all references, documents, policies, and procedures
related to claims to ensure correct application of contract
benefits between HMSA and Managed Service Provider(s)
- Analyze and interpret business documents such as HMSA's Medical
Policy Manual, plan certificates and Guide to Benefits, statistical
data, product development memos and documents published by Blue
Cross and Blue Shield Association related to compliance; the
literature from Federal and/or state governments pertinent to the
business (i.e. Federal Register, CMS guidelines, Hawaii Revised
- Ensures all appropriate processes are followed and
documentation is completed as required by acting as quality control
checkpoint verifying standards are adhered to.
- Proactively solve conflicts and address issues that could occur
between HMSA, customers, and service providers
- Maintain knowledge of current health plan related to claims and
- Perform all other miscellaneous responsibilities and duties as
assigned or directed.
Keywords: HMSA, Honolulu , Claims Operations Specialist, Other , Honolulu, Hawaii
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