Claims Operations Specialist

The Company: AlohaCare is a local, non-profit health plan serving the Medicaid

and Medicare dual eligible population.

We provide comprehensive managed care to qualifying health plan members

through well-established partnerships with quality health care providers and community-governed

health centers. Our mission is to serve individuals and communities in the true

spirit of aloha by ensuring and advocating access to quality health care for

all. This is accomplished with emphasis on prevention and primary care through community

health centers that founded us and continue to guide us as well as with others

that share our commitment. As Hawaii’s third-largest health plan, AlohaCare

offers comprehensive prevention, primary and specialty care coverage in order

to successfully build a healthy Hawaii.

The Company: AlohaCare employees share a passion for helping Hawaii’s most

underserved communities. This passion

for helping and caring for others is internalized and applied to our employees

through a supportive and positive work environment, healthy work/life balance,

continuous communication and a generous benefits package. AlohaCare’s leadership empowers and engages its employees through

frequent diversity, recognition, community, and educational events and

programs. AlohaCare has a strong commitment to support Hawaii’s families and

reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and

trust with both our internal and external customers, we encourage open-door,

two-way communication through daily interactions, employee events and quarterly

all-staff meetings. AlohaCare’s comprehensive benefits package includes low

cost medical/vision, dental, and drug insurance, Paid Time Off (PTO) Plan, 401k

employer contribution, referral bonus and pretax transportation and parking

program. These employee-focused efforts contribute to a friendly,

team-oriented culture which is positively reflected into the communities we

serve. The

Opportunity: The Claims Operations Specialist will be responsible for a

business process within the claims department such as Cost Share, Claims

Recovery and Claims Resolution. This

individual will provide outreach to Members, Providers, as well as work with

internal departments to resolve issues in a timely manner. The Claims

Operations Specialist will create/update Business Process flows, Desk Level

Procedures, and Training Documents for primary work areas (Cost Share, Claim

Recovery and Claim Resolution). Primary Duties and Responsibilities: Cost Share:

Manages

member cost share business processes including conducting member and

provider outreach, generating invoice letters, adjusting claims when

appropriate.

Investigates

and analyzes department processes and works with other departments (Enrollment,

Finance and Service Coordination) to improve the recovery of cost share

and processing of claims with cost share.

Claims Recovery:
Researches

and analyzes claims data to identify potential recoveries.

Investigates

department processes and works with Enrollment Department to identify

issues that cause claims to be recovered.

Works

with Enrollment Department staff to identify, resolve and reduce member

eligibility related issues that cause the inaccurate processing of new

claims.

Works

with Data Analysis staff to develop recovery identification and monitoring

reports.

Works

with Business Support Service staff to modify claims adjudication

processes that cause the inaccurate processing of new claims.

Performs

claim adjustments as required.

Claims Resolution:
Researches

and analyzes claims data to identify potential issues that cause the

inaccurate processing of claims which impact providers.

Responds

to Provider Inquires through either written or verbal communication

Investigates

department processes and works with other departments such as Credentialing,

Contracting, Customer Service, Provider Relations and Enrollment to

identify issues that result in the inaccurate processing of claims.

Works

with Data Analysis staff to develop claim denial monitoring reports.

Works

with Business Support Service staff to modify claims adjudication

processes that cause the inaccurate processing of new claims.

Performs

claim adjustments as required.

Other

Duties and Responsibilities:
Reviews

Medicare, State and Federal Correspondence to advise Claims Management

staff of requirement changes that could impact business processes.

Assists

with documenting business requirements for configuration changes.

Reviews

business process for opportunities for Improvement and provides

recommendations.

Conducts

system/upgrade testing as needed.

Fosters

collaborative relationships with internal customers.

Reviews

claims reporting data to identify trends and track Claims KPIs.

Supports

Internal Claims Audit Processes.

Assists

with new hire Trainings and on-boarding.

·

Responsible to

maintain AlohaCare’s confidential information in accordance with AlohaCare

policies, and state and federal laws, rules and regulations regarding

confidentiality. Employees have access to AlohaCare data based on the

data classification assigned to this job title.Requirements:
High

school diploma or equivalent

Minimum

of two years of claims processing experience and or equivalent combination

of education, experience and credentialing.

Equivalent

combination of education, experience and credentialing.

Excellent

verbal and written communication skills required.

·

Excellent attendance, must be punctual and

reliable·

Experience in operation of general office

equipment to include; PC, fax/copy machine and ACD Mitel Phones.·

Intermediate skill using Microsoft Programs;

Word, Excel, and Outlook·

Must have the ability to read, analyze, and

interpret business documents such as Claims workflows, Medical Policies,

Medicare and Medicaid Guidelines. ·

Ability to perform advance claims research, problem

identification and claims resolution.·

Possess an in-depth knowledge of CPT,

ICD-(/ICD-10, HCPCS, UB04 form, and CMS-1500 forms as they relate to insurance

payment to meet Health care insurance and medical coding, billing and payment

guidelinesPreferred Requirements ·

Bachelor’s Degree: Business Administration,

Accounting, or related field·

Previous experience with Medical Claims

Processing or Billing ·

Previous experience with QNXT·

Previous experience

with Medicaid or Medicare program.·

Health care industry

experience within managed care, hospital, medical office or equivalent.·

Collections or payment recoveries experience·

Working knowledge of SQL Server Management

Studio or other similar reporting productMental, Physical and Environmental

Demands: ·

Sedentary Work:
Exerting up to 20 pounds of force occasionally and/or a negligible amount of

force frequently or constantly to lift, carry, push, pull, or otherwise move

objects. Sedentary work involves sitting most of the time, but may involve

walking or standing for brief periods of time. ·

Inside working

conditions ·

No environmental

hazards ·

Requires operation

of general office equipment to include PC AlohaCare is committed to providing equal employment opportunity

to all applicants in accordance with sound practices and federal and state

laws. Our policy prohibits

discrimination and harassment because of race, color, religion, sex (including

gender identity or expression), pregnancy, age, national origin, ancestry,

marital status, arrest and court record, disability, genetic information,

sexual orientation, domestic or sexual violence victim status, credit history,

citizenship status, military/veterans status, or other characteristics

protected under applicable state and federal laws, regulations, and/or

executive orders.