Health Plan Operations Specialist

Under general supervision, oversees coordination and analysis of payable claims to outside vendors for services provided to plan participants. This position ensures timely and accurate processing and payment of claims by the Third-Party Administrator through competent review of claims adjudication compared to network contracts and current government assigned rates. Assists in resolving discrepancies in the claim-authorization process, maintains internal and external spreadsheets of government payer and participant payments and receivables, and aids the Finance Manager through back office support required for appropriate data and financial reporting. Works with contracted, new, and potential network vendors regarding claims processing and payment concerns and appeals to facilitate the accounts payable process within the plan. Provides financial information data and support required for decision making and process improvement functions of the PACE Leadership Team.

Responsibilities

• Oversee coordination and analysis of payable claims to outside vendors for services provided to plan participants.
• Ensure timely and accurate processing and payment of claims by the Third-Party Administrator through review of claims adjudication compared to network contracts and government rates.
• Resolve discrepancies in the claim-authorization process.
• Maintain internal and external spreadsheets of government payer and participant payments and receivables.
• Provide back office support to the Finance Manager for data and financial reporting.
• Work with contracted, new, and potential network vendors on claims processing, payment concerns, and appeals.
• Provide financial information and support for decision making and process improvement functions of the PACE Leadership Team.

Requirements

• Associate’s Degree (required).
• 3 years of directly related work experience in insurance follow-up, billing, or collections may be considered in lieu of a degree.
• Minimum of 3 years of directly related work experience in insurance follow-up, billing, or collections in a hospital, collection agency, or physician office setting.
• Demonstrated analytical skills.
• Proficiency with Microsoft Word, Excel, and Outlook.

Qualifications

• Bachelor’s Degree (preferred).
• Five years of working experience in healthcare or health insurance-related field (preferred).

Benefits

• Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health, and telemedicine services.
• Wellbeing support, including free counseling and referral services.
• Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage, and leaves of absence.
• Savings and retirement resources, including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support, and financial wellbeing counseling.
• Education support through tuition assistance, student loan assistance, certification support, dependent scholarships, and a partnership with Galen College of Nursing.
• Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection, and consumer discounts.

Note: Eligibility for benefits may vary by location.