Operations Specialist

Individual incumbents may be responsible for a general overview or may specialize in one or more of the function areas of Operations listed below:

Claims Examiner:

The Claims Examiner Specialist reviews and adjudicates paper/electronic claims.  Determines whether to return, deny or pay claims following organizational policies and procedures.

• Responsible for duties related to the processing of complex claims in accordance with company, state and federal policies and regulations.

• Conducts special research that is unique in nature related to calculation of claims and claims processes.
• Answers questions, conducts quality reviews and mentors employees.

• Handles reports and/or special projects including, but not limited to: intake and resolution of cash, payments of interest, and/or accuracy reviews.

Customer Advocates:

The Customer Advocate Specialist coordinates research across departments to define and solve complex problems.  Communicates with external stakeholders to investigate, resolve and explain operations-related issues.  Identifies plan trends and propose solutions that enhance the members experience.

• Provides customer service via phone, email and/or written correspondence to groups, broker clients and members.
• Resolves customer problems, recommends modifications to products/services, and coordinates sales negotiation between customers and the organization.
• Explains benefits, claim filing procedures, rate increases, benefit upgrades and other situations that may arise.
• May act as concierge for “key/major” accounts identified by the organization.  Expert in the accounts assigned.

Enrollment & Billing:

The Enrollment & Billing Specialist duties are varied and require a thorough knowledge of enrollment and billing activities for the membership.

• Resolves issues that generate or may generate inquiries when the supervisor is not available.
• Recognizes and assists staff to recognize abnormal or incomplete application or resolution requests, inaccurate rating configuration or network setup or any other errors linked to system configuration issues.
• Answers questions and assists other departments in resolving enrollment eligibility transactions/inquiries.
• Responsible for duties related to the electronic filing of complex enrollment transactions in accordance with company, state and federal policies and regulations.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.