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Health Plan Claims System Support Specialist

4 months ago

Austin, United States Central Health Full time

Overview:
As the Health Plan Claims System Support Specialist for a Health Maintenance Organization (HMO) and other Health Plans based in Texas, you will implement within the claims management system software the manual non-automated configuration process and report design as needed to optimize the claims process and coordinating functions.

**Responsibilities**:

- Complete manual non-automated updates and creation of benefit plans in the claims management system software based on plan design provided by the Health Plan Benefit Team.
- Performs overall claims management system planning, implementation, and administration.
- Perform manual non-automated updates and creation of the contracted Provider's fee schedule in the claims management system software provided by the Health Plan Provider Network Team.
- Manage the Users and their Permissions within the claims management system software.
- Prioritize and triage assistance requests.
- Manual non-automated updates of the enrollment configuration to support the Health Plan.
- Collaborate with Health Plan Departments to develop ad-hoc and additional standardized reports within the claims management software system.
- Leverage reporting and data to support the claims process.
- Ensure accurate reporting of incidents or events along with documented procedures.
- Collaborate with Health Plan Departments, such as Clinical, Claims, Operations, Member Services and Financial to develop processes to support their needs from the claims management software system.
- System Enhancement and Training: Attend training sessions with the claims management system software vendor to understand system changes and enhancements.
- Train Health Plan Departments on claims management software system changes that effect their functionality.
- Maintain detailed documentation of methodologies, processes, and specifications of the claims management system and assist with the planning and scheduling of system improvements and initiatives.
- Coordinate with outside vendors to ensure their resources are managed to meet standards of operations within the claims management system software.
- Coordinate with the Health Plan Compliance Department to ensure that the claims management system software is meeting all regulatory requirements.
- May perform other duties as assigned.

**KNOWLEDGE/SKILLS/ABILITIES**:

- Thorough understanding of health plan claim systems processing principles, coding systems, and reimbursement methodologies.
- Proficiencies in utilizing claim processing software and systems (VBA preferable), with a track record of driving system enhancements and process improvements.
- Excellent communication, and interpersonal skills, with the ability to coordinate with Health Plan Departments to achieve organizational goals.
- Thorough knowledge of health plan regulatory compliance requirements, including HIPAA, CMS Guidelines, and Texas regulations.
- Analytical mindset with the ability to interpret complex data, identify trends, and implement data-driven solutions.
- Demonstrated ability to effectively manage multiple priorities in a fast-paced environment while maintaining attention to detail and accuracy.
- Ability to build rapport and elicit problem details from customers and vendors.
- Ability to produce accurate reports, review data, and system documentation.
- Strong problem solving skills with the ability to adjust to frequently to changing priorities.
- Excellent verbal communication skills.

Qualifications:
**EDUCATION**:

- High School Diploma required.
- Bachelor's Degree in Healthcare Administration, Business Management, or related field preferred.

**EXPERIENCE**:

- 4 years experience in Health Plan Claims System processes, preferably with an HMO or managed care environment required.