Claims Operations Specialist

Company: AlohaCare
Location: Honolulu
Posted on: March 20, 2023

Job Description:

The Company: 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. This is accomplished with emphasis on prevention and primary care through community
health centers that founded us and continue to guide us as well as with others
that share our commitment. As Hawaii's third-largest health plan, AlohaCare
offers comprehensive prevention, primary and specialty care coverage in order
to successfully build a healthy Hawaii.
The Company: AlohaCare employees share a passion for helping Hawaii's most
underserved communities. This passion
for helping and caring for others is internalized and applied to our employees
through a supportive and positive work environment, healthy work/life balance,
continuous communication and a generous benefits package. AlohaCare's leadership empowers and engages its employees through
frequent diversity, recognition, community, and educational events and
programs. AlohaCare has a strong commitment to support Hawaii's families and
reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and
trust with both our internal and external customers, we encourage open-door,
two-way communication through daily interactions, employee events and quarterly
all-staff meetings. AlohaCare's comprehensive benefits package includes low
cost medical/vision, dental, and drug insurance, Paid Time Off (PTO) Plan, 401k
employer contribution, referral bonus and pretax transportation and parking
program. These employee-focused efforts contribute to a friendly,
team-oriented culture which is positively reflected into the communities we
serve. The
Opportunity: The Claims Operations Specialist will be responsible for a
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.

Claims Resolution:
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.
Works
with Business Support Service staff to modify claims adjudication
processes that cause the inaccurate processing of new claims.
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.
Reviews
business process 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 on-boarding.
-
Responsible to
maintain AlohaCare's confidential information in accordance with AlohaCare
policies, and state and federal laws, rules and regulations regarding
confidentiality. Employees have access to AlohaCare data based on the

data classification assigned to this job title.Requirements:
High
school diploma or equivalent
Minimum
of two years of claims processing experience and or equivalent combination
of education, experience and credentialing.
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 advance claims research, problem
identification and claims resolution. -
Possess an in-depth knowledge of CPT,
ICD-(/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
guidelinesPreferred 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 productMental, 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. Sedentary work involves sitting most of the time, but may involve
walking or standing for brief periods of time. -
Inside working
conditions -
No environmental
hazards -
Requires operation
of general office equipment to include PC AlohaCare is committed to providing equal employment opportunity
to all applicants in accordance with sound practices and federal and state
laws. Our policy prohibits
discrimination and harassment because of race, color, religion, sex (including
gender identity or expression), pregnancy, age, national origin, ancestry,
marital status, arrest and court record, disability, genetic information,
sexual orientation, domestic or sexual violence victim status, credit history,
citizenship status, military/veterans status, or other characteristics
protected under applicable state and federal laws, regulations, and/or
executive orders.

Keywords: AlohaCare, Honolulu , Claims Operations Specialist, Other , Honolulu, Hawaii