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Job description
Health Operations Claims SpecialistReporting to the Supervisor, Health Services Quality Assurance, the Health Operations Claims Specialist will play a key and collaborative role in the delivery of high-quality customer service to our 180,000+ plan participants in support of the 32BJ Health Fund's mission of providing high-quality and low-cost health benefits to union members and their families. This position serves as a subject matter expert for claims-related inquiries and works closely with members, providers, vendors, and internal departments to ensure accurate and timely claims processing and resolution.Essential Duties and Responsibilities:Maintain deep expertise of the Fund's covered benefits.Evaluate claims to determine if they are appropriately processed based on eligibility, provider contracting rules, and the Funds' plan design.Research claims and the third-party administrator's medical management policies to understand the impact against the Health Fund's plan specifications.Works with third-party administrator's claims processing team to review eligibility, benefit design and system processing issues.Support Health Fund management to identify and resolve plan design, member, provider, and appeal-related issues.Conduct member outreach to address and resolve claims-related inquiries.Communicate with facilities and providers regarding complex claims submissions, including requests for supporting documentation and claim resubmission.Self-assign CRM cases during high-volume periods.Identify and resolve potential/actual claims problems and document root cause analysis; present findings to management and create formal reports for upper leadership.Maintain detailed information on claims issues and ensure that appropriate and comprehensive data is tracked and updated timely.Improve quality, enhance workflows, identify opportunities for improvements and interdepartmental efficiencies and develop and present recommendations for changes.Collaborate with vendors and clinical partners to troubleshoot claims issues.Conduct member outreach for claims inquiry resolution.Contact facilities and providers regarding complex claims submissions and the need for required documentation and/or claim resubmission.Effectively utilize the Fund's member/employer database to research and verify member's eligibility, benefits, and communications.Provide additional support as directed by senior leadership and management.Qualifications (Competencies):2+ years of work experience in health insurance claims, claims operations, or health billing required.Extensive knowledge of claim processing policies and procedures, including hospital/medical claims, understanding the basics of ICD-10 coding, CPT codes, HCPCS codes, DRG coding, place of service, provider ids (TINS, NPIs), amounts paid, and out of pocket costs.Strong knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement required.Prior knowledge with healthcare regulations and claims compliance requirements preferred.Excellent verbal, written communication, analytical, and problem-solving skills.Ability to identify trends and recommend process improvements.Experience accurately interpreting information from contractual and technical perspectives.Ability working on multiple projects with competing priority levels.Proficiency with MS Office applications (Word, Excel, PowerPoint).Soft Skills (Interpersonal Skills):Strong organizational and time management skills.Ability to maintain confidentiality and exercise discretion when handling sensitive information.Effective communicator with experience partnering with senior leaders and external partners.High degree of professionalism, integrity, and accountability.Demonstrated commitment to continuous learning, quality improvement, and operational excellence.Strong actively listening skills, attention to detail and commitment to accuracy when reviewing claims, documentation, and benefit information.Ability to work independently while contributing to team objectives.Education:High School Diploma, GED, or combined work experience and education.Reasoning Ability: HighPhysical Demands:The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals to perform the essential functions.Under 1/3 of the time: Standing, Walking, Climbing or Balancing, Stooping, Kneeling, Crouching, or CrawlingOver 2/3 of the time: Talking or Hearing100% of the time: Using HandsWork Environment:The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.1/3 to 2/3 of the time: Work near moving or mechanical parts, exposure to radiation, moderate noise.
Worksite address
new york, NY, 10001, US
Who can apply
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