Operations Specialist, Associate
2 weeks ago
Your Role
The Provider Escalations team (within the Claims Organization) partners with Network Management, Claims Leadership, and internal business partners to resolve post-appeal claims issues for our providers. The Associate Operations Specialist will report to the Senior Manager of the Claims Partnerships and Communications team. In this role you will have the opportunity to research claims issues to determine their root cause, partner internally to remediate issues, and walk providers through issue resolution or educational opportunities, as needed.
Your Work
In this role, you will:
- Act as subject matter expert and review operational workflows, identifying problems and acting as a SME to inform improvements, modifications, and enhancements
- Track and communicate workflow and system changes to appropriate resources
- Review systems and applications and recommend system edits/changes as needed
- Notify appropriate department mangers about issues and problems in operational workflow requiring immediate attention
- Participate as a subject matter expert to inform the development of written guidelines and documents problems as needed
- Leverage your claims knowledge to initiate resolution at the root cause of issues and ensure avoidance of future issues
- Have the ability to work with internal partners to facilitate issue resolution; as well as, when needed, explaining our issue resolution plans and / or provide an explanation of claims processing for our providers in concert with Network Management
- Combine your passion for claims with your desire to learn about identifying larger scale claims issues with data analysis
- Be a critical member of a collaborative, fantastic team
Your Knowledge and Experience
- Requires a bachelor’s degree or equivalent experience
- 0-2 years of prior relevant experience
- Requires an analytical mindset, ability to determine root cause of a claims issue, as well as upstream and downstream impacts
- Requires an agile attitude, ability to change directions and prioritization when needed.
- Requires Facility and Professional claims processing knowledge and experience and the FACETS system.
- Requires communication skills, and the ability to translate claims processing information / processing rules into language all can understand
- Requires knowledge of MS Office Applications and perform claims analysis in Excel. Preferred knowledge and/or ability to run reporting in Business Objects
- Desired HEAT (Hospital Exception and Transplant processing experience) skillset and knowledge
Pay Range:
The pay range for this role is: $ 26.20 to $ 36.68 per hour for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
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