Client Operations Success Specialist
4 weeks ago
The Client Operational Success Specialist plays a critical role in delivering exceptional support to our clients, ensuring seamless communication and issue resolution between Client Services and Operations. This position requires expertise in both Eligibility and Claims Functions, with a strong focus on implementation support, client day-to-day support, and issue resolution management.
Key Responsibilities- Implementation Support: Collaborate with clients to guide new group implementations, ensuring smooth system configuration and testing.
- Client Day-to-Day Support: Provide timely and accurate responses to client inquiries, ensuring exceptional support related to billing, eligibility, and claim inquiries.
- Issue Resolution Management: Investigate and resolve escalated billing, eligibility, and claim questions within a target turnaround of 3-5 days.
- Claims Processing Knowledge: Utilize strong knowledge of claims processing, including high-dollar claims, TPL issues, vendor disputes, and potential stop-loss matters, to assist in issue resolution.
- Reporting and Data Entry: Enter billing, eligibility, and claims information, monitor workflow, and provide status reports on processing progress.
- Communication with Internal Teams: Collaborate closely with Senior Claims Analysts, Client Services, and Customer Service to ensure proper handling and communication regarding claim and eligibility issues.
- Audit and Quality Control: Oversee processing quality reviews, conduct audits, and provide feedback on accuracy. Identify trends and systemic root causes for continuous improvement.
- Training and Support: Assist in training staff on processes and best practices, fostering a clear understanding of requirements and documentation associated with dedicated accounts.
- Policy Adherence: Ensure all eligibility determinations comply with company policies and client plan documents.
- Eligibility Expertise: Strong understanding of eligibility requirements, documentation, and related regulations.
- Claims Expertise: In-depth knowledge of claims processing, coding structures (CPT, HCPCS, ICD-9/10), and claims pricing methodologies (Network, Medicare, RBP, UCR).
- Excellent Communication Skills: Ability to effectively communicate complex information to clients and colleagues.
- Organizational Skills: Demonstrated ability to maintain accurate records and manage time efficiently.
- Team Collaboration: Ability to work effectively within a team environment and provide training support to colleagues.
- Commitment to Compliance: Ensure adherence to company policies, procedures, and HIPAA regulations.
- Regular, predictable attendance is required.
- Ability to collaborate effectively with colleagues across both eligibility and claims functions.
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