Operations Specialist, Senior (Medicare Claims)

About the role

The Medicare Operations Claims team reviews and resolves Medicare claims processing questions and issue requests. This includes conducting comprehensive analyses, assessing impact, and implementing appropriate remediation at both the individual claims and plan levels. The Operations Specialist Senior will report to the Claims Operations Director.

Responsibilities

• Serve as subject matter expert to review complex workflows, identify issues, and drive process improvements.
• Ensure claims processing aligns with CMS requirements and compliance standards.
• Monitor, document, and communicate workflow and system changes to stakeholders.
• Evaluate systems/applications and recommend enhancements or corrective actions.
• Develop tools, processes, and reporting to improve efficiency, accuracy, and visibility.
• Lead training, documentation, and guideline development; educate on complex topics.
• Operate independently while managing projects and providing guidance, coaching, and cross-functional collaboration.

Qualifications

• Requires a college degree or equivalent experience and minimum 5 years of prior relevant experience.
• Requires Medicare claims knowledge and processing experience.
• Demonstrates strong verbal and written communication skills.
• Ability to work independently and operate as a self-starter who takes initiative.
• Exhibits strong critical thinking and problem-solving skills.
• Demonstrates strong prioritization and multi-tasking abilities.
• Maintains overall accountability and ensures tasks are followed through to completion.
• Possesses advanced knowledge of the job area, typically gained through a combination of advanced education and experience; may include practical project management knowledge.

About Us

About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Physical Requirements

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail.

Equal Employment Opportunity

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.