Health Operations Claims Specialist

Building Services 32BJ Benefit Funds (“the Funds”) administers Health, Pension, Retirement Savings, Training, and Legal Services benefits to over 185,000 SEIU 32BJ members. Our mission is to provide high-quality benefits and services, overseeing $11 billion in assets from property owners and other sources. We drive innovation, equity, and technology insights using tools like M365, Dynamics 365 CRM, Dynamics 365 F&O, Azure, AWS, SQL, Snowflake, and QlikView.

About the role

Reporting to the Supervisor, Health Services Quality Assurance, the Health Operations Claims Specialist plays a key and collaborative role in delivering high-quality customer service to over 180,000 plan participants. This position serves as a subject matter expert for claims-related inquiries, working closely with members, providers, vendors, and internal departments to ensure accurate and timely claims processing and resolution.

Responsibilities

• Maintain deep expertise of the Fund's covered benefits.
• Evaluate claims to determine if they are appropriately processed based on eligibility, provider contracting rules, and the Funds' plan design.
• Research claims and the third-party administrator's medical management policies to understand the impact against the Health Fund's plan specifications.
• Work with the third-party administrator's claims processing team to review eligibility, benefit design, and system processing issues.
• Support Health Fund management to identify and resolve plan design, member, provider, and appeal-related issues.
• Conduct member outreach to address and resolve claims-related inquiries.
• Communicate with facilities and providers regarding complex claims submissions, including requests for supporting documentation and claim resubmission.
• Self-assign CRM cases during high-volume periods.
• Identify and resolve potential/actual claims problems and document root cause analysis; present findings to management and create formal reports for upper leadership.
• Maintain detailed information on claims issues and ensure that appropriate and comprehensive data is tracked and updated timely.
• Improve quality, enhance workflows, identify opportunities for improvements and interdepartmental efficiencies, and develop and present recommendations for changes.
• Collaborate with vendors and clinical partners to troubleshoot claims issues.
• Effectively utilize the Fund's member/employer database to research and verify member's eligibility, benefits, and communications.
• Provide additional support as directed by senior leadership and management.

Requirements

• 2+ years of work experience in health insurance claims, claims operations, or health billing required.
• Extensive knowledge of claim processing policies and procedures, including hospital/medical claims, ICD-10 coding, CPT codes, HCPCS codes, DRG coding, place of service, provider IDs (TINS, NPIs), amounts paid, and out-of-pocket costs.
• Strong knowledge of medical terminology, ICD/CPT coding, per diem, and DRG reimbursement required.
• Prior knowledge of healthcare regulations and claims compliance requirements preferred.
• Excellent verbal, written communication, analytical, and problem-solving skills.
• Ability to identify trends and recommend process improvements.
• Experience accurately interpreting information from contractual and technical perspectives.
• Ability to work on multiple projects with competing priority levels.
• Proficiency with MS Office applications (Word, Excel, PowerPoint).

Skills

• Strong organizational and time management skills.
• Ability to maintain confidentiality and exercise discretion when handling sensitive information.
• Effective communicator with experience partnering with senior leaders and external partners.
• High degree of professionalism, integrity, and accountability.
• Demonstrated commitment to continuous learning, quality improvement, and operational excellence.
• Strong active listening skills, attention to detail, and commitment to accuracy when reviewing claims, documentation, and benefit information.
• Ability to work independently while contributing to team objectives.

Qualifications

• High School Diploma, GED, or combined work experience and education.

Physical Demands

• Under 1/3 of the time: Standing, walking, climbing or balancing, stooping, kneeling, crouching, or crawling.
• Over 2/3 of the time: Talking or hearing.
• 100% of the time: Using hands.

Work Environment

• 1/3 to 2/3 of the time: Work near moving or mechanical parts, exposure to radiation, moderate noise.